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Introduction
In this paper, we focus on some of the key Chinese herbal formulas that may be used in the treatment of emotion-related disorders. The central concept is that extremes of emotion not only impair normal mental and emotional functioning; but also become pathogenic factors, affecting the internal organ systems to produce physical, emotional and behavioural abnormalities.
In part one, we explored the ancient Five Elements paradigm in relation to both normal and extreme emotions. This paradigm allowed us to map the psyche and create a model that includes both healthy, positive mental-emotional activities as well as disordered psychological states. Building on this material, the following discussion of Yu (stagnation) syndrome is centered on subsequent developments within TCM, the application of which allows more precision when prescribing herbal formulas.
As mentioned at the beginning of part one, the theoretical basis of contemporary TCM consists of several intersecting paradigms. The paradigm represented by Yu (stagnation) syndrome relates directly to the development of pathological changes that occur together with emotional distress, analyzed according to the internal organs and the physiological substances (i.e. the Qi, Blood, body Fluids and Essence). In this way, the observable changes that are brought about by pathogenic emotions may be understood in sufficient detail to allow accurate prescribing of herbal medicines.
Yu (stagnation) syndrome
The progression of pathological changes that may arise due to emotional distress is best illustrated by examining the disease class referred to in Chinese as yu zheng. This term is often translated as ‘depression’, ‘melancholia’, stagnation syndrome’, etc. (Maciocia, 1995, pp.344-5; Peng, 2000, p.350, Zhang, 2007, pp.87-104). However, there are no precise English words that capture the full meaning. The term yu (pronounced with the German vowel sound: ‘yü’) refers to stagnation, or disruption to the free movement, of the Qi (vital energy) that occurs as a direct result of emotional strain, primarily affecting the Liver, the main function of which is to ensure the smooth and even flow of the Qi throughout the body. Moreover, the Liver is the organ most readily affected by extremes of emotion. The term zheng (pronounced with a short vowel: ‘jung’) refers to diagnosis according to syndrome (or pattern) differentiation and is often translated as ‘disorders’, ‘patterns’ or ‘syndromes’.
Rather than being a single syndrome, however, the term, ‘Yu syndrome’, refers to several different, yet related, syndrome-patterns[i] that may arise as a result of the impact of extreme emotions on the Liver. The preferred terms in the following discussion are ‘Yu syndrome’ and ‘Stagnation syndrome’, which are used interchangeably.
The concept behind Yu syndrome is that various related pathological changes may develop from and successively overlie the primary, or original, organ imbalance caused by emotional overstimulation. Thus, there is a pathological progression over time, in which several sequential, and often cumulative, pathological changes may arise under conditions of severe and/or prolonged emotional strain.
The following stages of development within Yu syndrome describe the various ways in which pathological changes may develop. These stages are not to be understood in a rigid way, as if all of these pathologies will develop in a particular patient and unwaveringly follow in the order that has been described. Rather, these stages should be taken to indicate the possible ways in which pathological developments may arise, and to provide insights into the underlying imbalances that may also need to be addressed in patients who present with emotion-based disorders.
[i] In this paper the terms ‘syndrome’, ‘pattern’ and ‘syndrome-pattern’ are used interchangeably.The concept of stagnation
Before discussing the progression of pathological changes in Yu syndrome, it is appropriate for us to review the idea of stagnation, which is central to this discussion, as TCM views the essential mechanism behind the various manifestations of emotion-based problems in terms of stagnation of the Qi.
Under normal conditions, the Qi promotes and sustains normal functional activities of all bodily organs and tissues. In order to do this, the Qi must be able to move freely throughout the body. The Qi not only circulates via the channel system, it also needs to move in a particular manner within each of the various organ systems. These specific types of movement are described as: ascending, descending, entering and exiting. Thus, the respiratory movement of the lungs (entering of the Qi with inhalation; exiting of the Qi with exhalation); the movement of food through the GIT during digestion (descending of the Qi), are examples of how a specific type of Qi movement enables the normal activities of the internal organs.
Qi stagnation denotes a state in which the Qi is inhibited in its normal movement. This disturbance may occur within in an organ (e.g. the Liver), or tissue (e.g. muscles or joints), or may affect an area of the body (e.g. the chest or upper abdomen). The sensation of mild pain or discomfort with a full or distending sensation is a characteristic symptom associated with this phenomenon. When the stagnation is more severe and begins to affect the movement of the Blood, the pain becomes more intense and more clearly localized.
If we take the analogy of traffic moving through the streets of a populous city, stagnation of the Qi is like the flow of traffic during peak hour when a set of traffic lights has broken down. Movement is impeded and the traffic banks up at the affected intersection. Thus, the inhibited flow of traffic causes a build-up in the number of cars on the road. In the same way, stagnation of the Qi causes a build-up of Qi within an organ or part of the body, and this creates an excess type of condition. In addition, the irritation and frustration that may be felt by the drivers who are stuck in a traffic jam is analogous to the pathogenic Heat that is produced whenever there is stagnation in the body.
In the following discussion, it is important to note that stagnation of the Qi generally causes pain or discomfort, leads to an excess condition in the affected organ, and in time may develop pathogenic Heat.
Yu syndrome stage 1: Liver constraint, Qi stagnation
The physiological changes that occur in relation to our emotional responses are mediated by the Liver. In the wake of repeated and/or intense emotions, the response may become pathological, and the Liver begins to fail in its function of regulating the flow of Qi. This leads to the pattern of Liver constraint, characterized by stagnation of the Qi, with uneven Qi movement throughout the body. In addition, the Liver’s capacity to store and release the Blood is reduced, and this is described as Liver Blood deficiency.
Looking at a person’s emotional responses, the source of the problem may either be events in the external environment, or it may be self-generated, as when one repeatedly recollects and relives emotionally disturbing events. At this stage, a person begins to lose the ability to allow an emotional response to dissipate naturally, and experiences prolonged and overly intense emotional reactions. One may loose the ability to respond freely and appropriately to people and events, and to reach out emotionally to others. We would generally describe a person in this state as being ‘stressed’, ‘uptight’, ‘wound up’, or ‘edgy’. The relaxed and easy-going disposition, which is a sign of healthy Liver function, is notably absent.
The physical signs of Qi stagnation due to emotional strain include tightness or an oppressive sensation in the chest with the need to make an effort to take a deep breath, sighing, tightness in the shoulder muscles, sensation of fullness under the ribs, and sensation of a lump in the throat with difficulty swallowing.
Initially, this state, or condition, is easily reversible. Most people have sufficient self-awareness to know when these changes are occurring and sufficient self-esteem to take the necessary steps to relieve stress and remedy the situation. However, circumstances may prevent this, and the stresses may continue to accumulate.
Yu syndrome stage 2: Other organs are involved
Recalling the generation and control relationships that were discussed in part one, the pathological changes within the Liver may now become transmitted to the Heart (via the generation cycle) and the Spleen (via the control cycle). Depending on constitutional factors (i.e. organ strengths and weaknesses along with other tendencies), one pathway may be favored over another. At this stage, the pathological changes deepen as the Liver’s abnormal functioning affects the Heart and Spleen.
As mentioned above, one consequence of Liver constraint has to do with the Liver’s reduced capacity to store and release the Blood. This creates a condition of Blood deficiency in the Liver. Because of this, it is no longer able to adequately nourish the Heart, which then also becomes Blood deficient. Some characteristic signs of Heart Blood deficiency are insomnia, anxiety, depressed mood, forgetfulness, reduced ability to concentrate, palpitations and a thready pulse.
Additionally, the state of Qi stagnation within the Liver tends to give rise to Heat, which is the natural consequence of any type of stagnation. This Heat may subsequently develop into Fire. Fire is a state of extreme Heat that is marked by severe disruption of organ functioning, depletion of the body Fluids as well as the tendency to spread from its initial source. In this scenario, the Fire that has developed in the Liver transmits to the Heart, giving rise to extreme restlessness and irritability with insomnia, together with signs of Heat, such as mouth ulcers, thirst, red tongue, red complexion and rapid pulse.
Another possible scenario is that the Liver Qi ‘invades’ the Spleen via the control cycle. Stagnation of the Qi within the Liver creates an excess condition, resulting in the Liver ‘over-controlling’ the Spleen. This leads to a damping-down of Spleen function with signs of poor appetite, low energy, fatigue and muscular weakness. This state of Spleen Qi deficiency may eventually lead to a more generalized state of Qi and Blood deficiency, as the Spleen becomes unable to adequately process nutrients to replenish the Qi and Blood. Thus, a vicious cycle is created, worsening the condition of Blood deficiency in both the Liver and the Heart.
At this stage, a person may be aware of severe stress and therefore take more drastic measures to deal with the causes, such as finding different work, ending a destructive relationship, or taking more care with general health and fitness. The sense of self is still relatively intact, but there is an awareness of psychological distress and a sense of being injured or traumatized to some extent.
Yu syndrome stage 3: Development of endogenous pathogens
At this stage, impairment of internal organ function, specifically within the Liver and Spleen, allows the development of two important pathogenic factors: Phlegm and Blood stasis.
Phlegm may develop as a consequence of the Spleen’s impaired digestive functions, together with the Heat generated by stagnation within the Liver; while Blood stasis may arise as a consequence of Qi stagnation, facilitated by the state of Blood deficiency. For a person thus affected, at this stage it is no longer a question of having a bad day or a bad week; there is the distinct perception that ‘something is really wrong with me’, and there is a clear need to seek help.
Phlegm tends to worsen any form of stagnation that may be present. In addition, it may cloud the mind, leading to distorted perception and interpretation of events in the external environment, as well as unclear thinking. When there is also Heat, a person may experience agitation, severe irritability and insomnia. When extreme, the effect of Phlegm together with Heat or Fire may lead to delusions and mania. Thus, the presence of Phlegm, or Phlegm together with Heat, creates a psychological state that is extremely distressing, and which may negatively impact a person’s ability to maintain normal social as well as work relationships.
The other pathogenic factor that may develop at this stage, with equally deleterious consequences, is Blood stasis. When this develops, a person will also tend to feel a pressing need to seek professional help. Blood stasis tends to arise as a consequence of Qi stagnation, as the Blood relies on the Qi to maintain its normal movement throughout the body. When there is also a state Blood deficiency, the combined effect allows Blood stasis to occur more readily. In addition to progressive worsening of the mental and emotional state with pronounced mood swings, Blood stasis may give rise to dysmenorrhea in women, and headache or painful muscle spasms in either sex.
In the progressive scenarios described above, Phlegm and/or Blood stasis may develop quite rapidly, triggering a marked deterioration in the person’s sense of well-being as well as social and work-related functioning. This is the stage at which patients generally present to clinic, with several underlying organ imbalances, centred on the Heart, Liver and Spleen, together with internally generated pathogenic factors, i.e. Phlegm and/or Blood stasis.
Yu syndrome stage 4: Injury to the Yin
This is quite a severe development that may occur after an emotion related disorder has been prolonged and poorly treated, or not treated at all. The pathological progression continues to the point where the deepest levels of functioning are affected. In TCM this is signified by the Kidney, where cerebral, endocrine and general metabolic functions are seriously affected. At this stage, a patient requires long term treatment, focusing on symptom relief, together with progressively addressing the underlying organ imbalances, as they become manifest during the treatment process.
The pathogenesis of injury to the Yin is driven by two factors. On the one hand the Heat that has developed due to Qi stagnation becomes extreme, changing into Fire, and on the other, there is Blood deficiency.
Fire develops when pathogenic Heat becomes more intense and moves deeper into the body, causing injury to the Fluids and internal organ systems. The drying effect of Fire depletes the body Fluids, which draws on the Yin aspects of the body, as the body Fluids (along with the Blood) are its major components. This creates a generalised state of Yin deficiency, which tends to create a vicious cycle by generating more Heat, which worsens the effects of the Fire.
Blood deficiency, on the other hand, develops as a result of impaired Liver and Spleen functions. Moreover, with the development of Blood stasis, the condition of Blood deficiency is worsened, because impaired circulation of the Blood reduces the overall capacity of the Blood to provide nourishment to the various tissues and organ systems. The Blood is an important aspect of the Yin, just as the Qi is an important part of the Yang. Therefore, a prolonged or extreme state of Blood deficiency may manifest as Yin deficiency.
When these two pathways – the Fire from stagnant Heat and Blood deficiency – occur together, the bodily Yin may become depleted quite rapidly and this process eventually bankrupts the reserves of the Kidney, leading to a condition of Kidney Yin deficiency. One of the major consequences of Kidney Yin deficiency is hyperactivity of the Yang, as the Yang factors are no longer able to be held in check and balanced by the Yin factors. The unrestrained Yang creates pathogenic Heat or Fire, with symptoms such as sensations of heat, facial flushing, abnormal sweating, dry mouth and unquenchable thirst, together with other signs of excessive functional activity such as very high libido, restlessness and irritability.
When a patient has Kidney Yin deficiency together with Fire (i.e. extreme Heat) there is a deep sense of dysphoria, marked by dizziness or light-headedness, tinnitus, poor memory, sleep disturbance, inability to concentrate and possibly also confusion. The hyperactivity caused by the Fire may lead to hypervigilance, overexcitability, mental confusion and severe insomnia. Other characteristic symptoms include night sweating, afternoon fever, constant dry mouth and throat, hot hands and feet, sensations of heat in the chest, and facial flushing. This condition is generally complicated by the pathological developments of the preceding stages, so that there may also be Phlegm, Blood stasis, and various internal organ imbalances.
Patients at this stage have often been ‘diagnosed’ by their well-meaning GP and prescribed an antidepressant, in an attempt to ‘correct a chemical imbalance in the brain’. Unfortunately, there is no evidence to support this theory, and when the patient seeks out complementary medical help, the practitioner also has to deal with the harmful effects of SSRI dependency. Weaning a patient off such medications is best done slowly and under the direction of a sympathetic psychiatrist, who respects the value of complementary modalities.
Chart of pathological changes in Yu (stagnation) syndrome
Stage 1: Mainly Liver affected
- Liver constraint, Qi stagnation
Stage 2: Other organs involved
- Liver fails to nourish the Heart → Heart Blood deficiency
- Liver Qi invades the Spleen → Spleen Qi deficiency → Qi and Blood deficiency
- Liver develops stagnant Heat → Fire à transfers to Heart → Heart Fire
Stage 3: Development of Phlegm or Blood stasis (i.e. endogenous pathogens)
- Spleen Qi deficiency → impaired digestion and fluid metabolism → retained Damp → Phlegm
- Liver constraint → Qi stagnation → stagnant Heat → promotes development of Phlegm
- Phlegm affects the ‘Heart openings’ (clouds the mind)
- Qi stagnation (± Blood deficiency) → Blood stasis
Stage 4: Injury to the Yin
- Liver Heat due to Qi stagnation → Fire → dries the body Fluids and injures the Yin
- Blood deficiency → develops into Yin deficiency
- Yin deficiency → Kidney Yin deficiency → deficiency Heat or Fire ± Phlegm-Heat
Chart of representative Chinese herbal formulas in Yu syndrome
STAGE 1: Liver imbalance
- Xiao Yao San (Bupleurum & Danggui Formula) a.k.a. Stress Relief 2 Formula
- Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination) a.k.a. Qi Mover Formula
STAGE 2: Heart and Spleen affected
Heart Blood deficiency
- An Shen Ding Zhi Wan (Ziziphus & Polygala Formula).
Liver Qi invades the Spleen à Spleen Qi deficiency à Qi and Blood deficiency, affecting Heart and Spleen
- Gui Pi Wan (Ginseng & Longan Combination) a.k.a. Restore The Spleen Formula
Liver develops stagnant Heat
- Jia Wei Xiao Yao San (Bupleurum & Peony Formula) a.k.a. Stress Relief 1 Formula
Stagnant Heat à Fire à transfers to Heart à Heart Fire
- Huang Lian Jie Du Wan (Coptis & Scute Formula) a.k.a. Antitox 2 Formula
STAGE 3: Development of Phlegm and Blood stasis
Phlegm:
- Wen Dan Tang (Bamboo & Hoelen Formula) a.k.a. Clear The Phlegm Formula
Blood stasis:
- Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination) a.k.a. Blood Moving 2 Formula
STAGE 4: Injury to the Yin
- Jin Gui Suan Zao Ren Tang (Ziziphus Combination)
- Tian Wang Bu Xin Wan (Ginseng & Ziziphus) a.k.a. Calm The Spirit Formula
REPRESENTATIVE CHINESE HERBAL FORMULAS IN YU SYNDROME
STAGE 1: Liver imbalance
At this stage, herbal formulas that address Qi stagnation due to Liver constraint are prescribed. Patients may present with either a deficiency or an excess pattern. Accordingly, the main formulas are:
- Xiao Yao San (Bupleurum & Danggui Formula) a.k.a. Stress Relief 2 Formula
- Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination) a.k.a. Qi Mover Formula
For patients who present with Liver constraint in a deficiency pattern, the appropriate treatment formula is Xiao Yao San (Bupleurum & Danggui Formula) a.k.a. Stress Relief 2 Formula.
Formula Ingredients
Bupleurum falcatum, root (chai hu)
Paeonia lactiflora, root (bai shao)
Angelica polymorpha, root (dang-gui)
Atractylodes macrocephala, rhiz. (bai zhu)
Poria cocos, fruit. body (fu ling)
Glycyrrhiza uralensis, root (gan cao)
Mentha haplocalyx, herb (bo he)
Zingiber officinale, rhiz. (sheng jiang)
The major herb in this formula is Bupleurum, which has been pre-prepared by dry frying. This focuses the herb’s action on the Liver and accentuates two of its main actions; one is to promote the Liver’s primary function of spreading the Qi to ensure its smooth and even movement throughout the body and the other action is to disperse the stagnant Qi. In addition, dry-fried Bupleurum acts as ‘envoy’ to direct the actions of the other herbs to the Liver. The formula acts to disperse the stagnant Qi (Bupleurum, Zingiber, Mentha) and to promote free movement of the Qi by nourishing and strengthening the Liver (Paeonia, Angelica). In addition, there is a group of herbs that strengthen the Spleen to promote Qi and Blood production (Atractylodes, Poria, Glycyrrhiza) as the Spleen’s functions may have become inhibited due to Liver constraint. This formula is suitable for patients experiencing the initial effects of emotional strain or stress, whose main symptoms are irritability, depressed mood, fatigue, and withdrawn disposition. There may also be signs of deficiency, such as pale complexion, fatigue, loss of appetite, pale tongue, and a weak-thready pulse (which is also wiry).
Patients presenting with Liver constraint in an excess pattern, require a slightly different treatment approach; the appropriate formula in these cases is Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination) a.k.a. Qi Mover Formula.
Formula Ingredients
Paeonia lactiflora, root (bai shao)
Cyperus rotundus, rhiz. (xiang fu)
Citrus aurantium, fruit (zhi ke)
Bupleurum falcatum, root (chai hu)
Ligusticum wallichii, rhiz. (chuan xiong)
Corydalis turtschaninovii, root (yan hu suo)
Curcuma longa, root (yu jin)
Glycyrrhiza uralensis, root (gan cao)
The major herb here is also Bupleurum, which has been pre-prepared by dry frying. It acts in the same way within this formula: to promote Liver function and disperse the stagnant Qi while also acting as envoy to direct the actions of the other herbs to the Liver. In contradistinction to the formula discussed above, this one does not have pronounced tonifying or nourishing actions – only Paeonia and Glycyrrhiza are included, to soothe the Liver and relieve muscular tension. This formula’s actions are focused on promoting Qi movement and dispersing stagnant Qi (Bupleurum, Cyperus, Citrus, Ligusticum, Corydalis, Curcuma) as well as activating the Blood (Ligusticum, Corydalis, Curcuma). The formula is used in conditions that have more severe stagnation of the Qi, together with the accompanying tendency to Blood stasis. Patients will have a robust constitution, a more outgoing temperament, be more expressive of their emotions and may also complain of physical discomfort due to muscular tension. The main symptoms are irritability, angry outbursts, and sensations of muscular tension and discomfort, with a full and wiry pulse.
STAGE 2: Other organs involved
Heart Blood deficiency
When Heart Blood deficiency develops, the main clinical manifestations are centered on disturbed sleep and mood. Initially these symptoms may be transient and readily reversible. However, once this condition becomes established, the characteristic symptoms will persist, in spite of removal of the original source of emotional strain. The appropriate treatment formula at this stage is An Shen Ding Zhi Wan (Ziziphus & Polygala Formula).
Formula Ingredients
Fallopia multiflora, stem (ye jiao teng)
Ziziphus jujuba var. spinosa, seed (suan zao ren)
Poria cocos, hyphae (fu ling)
Poria cocos, inner part with pine wood (fu shen)
Pseudostellaria heterophylla, root (tai zi shen)
Oyster shell (mu li)
Polygala sibirica, root (yuan zhi)
Anemone altaica, rhiz. (chang pu)
The major herbs are Fallopia and Pseudostellaria; the former nourishes the Heart Blood and the latter tonifies the Qi. Polygala acts as envoy to direct the actions of the formula’s ingredients to the Heart. The formula is composed mostly of Heart nourishing herbs (Fallopia, Pseudostellaria, two types of Poria, and Zizyphus), supported by the ‘settling’ action of Oyster shell and the ‘opening’ action of Polygala and Anemone. These supporting ingredients clear and calm the mind while also stabilizing the emotions. This formula has tonifying and nourishing actions on the Heart, and is effective for insomnia, mood swings, anxiety and depressed mood. Such patients will also show other clinical signs of Heart Qi and Blood deficiency, such as forgetfulness, palpitations, pale tongue and a weak-thready pulse.
Qi and Blood deficiency, affecting Heart and Spleen
Commonly, the repercussions of Liver constraint involve both the Heart and the Spleen. This is due to failure of the Liver to nourish the Heart with Blood, on the one hand; and failure to regulate and promote the functional activities of the Spleen, on the other. In addition, the repeated mental and emotional over-stimulation that results from worrying or obsessing about unpleasant events, both real and imagined, has a direct effect on these two organs, which further contributes to the state of deficiency. The classic formula to address this dual deficiency condition is Gui Pi Wan (Ginseng & Longan Combination) a.k.a. Restore the Spleen Formula.
Formula Ingredients
Astragalus membranaceus, root (huang qi)
Ziziphus jujuba var. spinosa, seed (suan zao ren)
Poria cocos, fruit. body (fu ling)
Codonopsis pilosula, root (dang shen)
Atractylodes macrocephala, rhizome (bai zhu)
Glycyrrhiza uralensis, root (zhi gan cao)
Angelica polymorpha, root (dang-gui)
Dimocarpus longan, fruit flesh (long yan rou)
Cyperus rotundus, rhizome (xiang fu)
Polygala siberica, root (yuan zhi)
Ziziphus jujuba, fruit (da zao)
Zingiber officinale, rhizome (sheng jiang)
The two principal herbs are Astragalus, which tonfies the Spleen Qi, and Zizypus seed, which nourishes the Heart and calms the spirit. The former herb is supported in its actions by Codonopsis, Atractylodes, Poria, Zizyphys fruit, Zingiber and Glycyrrhiza. The therapeutic actions of Zizyphus seed are supported by Angelica and Dimocarpus, which nourish the Blood, and also by Poria and Polygala, which calm the Spirit. Polygala has the additional role of envoy and directs the actions of the other herbs to the Heart. This formula is suited to patients with depressed mood, anxiety and insomnia with poor appetite, fatigue (both physical and mental), forgetfulness, a pale tongue and a weak-thready pulse.
Liver constraint, Qi stagnation develops stagnant Heat
Although this particular pattern on its own belongs in stage 1, it is discussed here because it is an important precursor to Heart Fire, discussed below as well as Phlegm (stage 3) and Yin deficiency (stage 4). It is a general principle in TCM that stagnation leads to the development of pathogenic Heat. This correlates closely with the concept of inflammation, whereby the body attempts to resolve or remove pathogenic substances. In addition, the Liver has certain innate properties that predispose to the development of Heat. It is classified as a Wood organ and belongs to the ‘young’ or developing stage of Yang, the nature of which is to readily flare up at the slightest provocation.
This pattern is commonly encountered in the clinic. The development of Heat (known as ‘stagnant’ Heat) due to Liver constraint leads to a marked worsening of the initial symptoms. Patients complain of extreme irritability, short temper, insomnia, stomach upset (particularly when stressed) and a general state of mental and emotional unrest. The classical formula suitable for such patients is Jia Wei Xiao Yao San (Bupleurum & Peony Formula) a.k.a. Stress Relief 1 Formula. This formula is the same as Xiao Yao San (Bupleurum & Danggui Formula) a.k.a. Stress Relief 2 Formula (discussed above), with the addition of two ingredients that address the stagnant Heat: Paeonia bark and Gardenia fruit (both dry-fried). The two formulas are used clinically in the much the same way; the main difference being that the former is stronger and acts more rapidly. However, the latter formula (Xiao Yao San) would be favored in patients presenting with fatigue; and the former (Jia Wei Xiao Yao San) in patients with irritability, sleep disturbance and obvious signs of Heat, e.g. sensations of Heat, red eyes, redness on the tongue and a rapid pulse (which is also wiry).
Heart Fire
When the stagnant Heat within the Liver has progressed to the point where it becomes Fire, it may transfer to the Heart. There is now a dramatic worsening of symptoms: the patient is in a constantly over-excited state that is no longer only brought on by stressful events. This is an excess type pattern, which is marked by a relatively sudden onset, and absence of fatigue or dizziness. It is referred to as Heart Fire. The classical formula that is used for such cases is Huang Lian Jie Du Wan (Coptis & Scute Formula) a.k.a. Antitox 2 Formula.
Formula Ingredients
Coptis chinensis, root (huang lian)
Scutellaria baicalensis, root (huang qin)
Phellodendron amurense, stem bark (huang bai)
Gardenia jasminoides, fruit (shan zhi zi)
The principal herb is Coptis, which purges Fire from the Heart. It is supported by the other herbal ingredients which purge Fire from various internal organ systems. This formula is suitable for patients with severe irritability, agitation, impulsiveness, insomnia and prominent signs of Heat, e.g. fever[ii], dark urine, mouth ulcers, dry mouth and throat, bitter taste in the mouth, red tongue with a yellow coat, rapid and forceful pulse.
STAGE 3: Development of Phlegm or Blood Stasis
Once the disruptive effects of emotional imbalance have affected the internal organs, their impaired functioning may lead to the development of endogenous pathogens, principally Phlegm and Blood stasis. These pathogens both worsen and perpetuate the original emotion-based problem, and this is the reason why the two formulas discussed below are able to provide dramatic relief in these patients, in spite of the fact that neither formula contains specific herbs that act to calm the Spirit and nourish the Heart.
Phlegm may manifest in various ways, which are classified into two broad categories: external Phlegm and internal Phlegm. External Phlegm manifests as sputum or excessive mucous, which is commonly seen in certain respiratory and digestive disorders. Internal Phlegm, as the name suggests, is more hidden and, although pathogenetically related to the external type of Phlegm, does not manifest with the clinical signs of excessive mucous or sputum.
Amongst the various internal manifestations of Phlegm, the ones that concerns us here are those that relate to the psyche, where internal Phlegm may cloud the mind and create obstruction to normal mental functions. Clinically this is seen when patients begin to entertain a skewed view of their present circumstances, e.g. worrying excessively about events that have not yet happened and may likely never happen; the belief that one will never again be happy; as well as various suspicions and delusions, which in normal circumstances would be dismissed with a light-hearted sense of self-deprecation.
The main representative formula for Phlegm that has developed as part of Yu syndrome is Wen Dan Tang (Bamboo & Hoelen Formula) a.k.a. Clear the Phlegm Formula. This formula is generally used in combination with one of the other formulas discussed in this section.
Formula Ingredients
Phyllostachys nigra, stem wood (zhu ru)
Poria cocos, fruit. body (fu ling)
Pinellia ternata, tuber (ban xia)
Citrus aurantium, fruit (zhi shi)
Citrus reticulata, fruit peel (chen pi)
Glycyrrhiza uralensis, root (gan cao)
Ziziphus jujuba, fruit (hong zao)
Zingiber officinale, rhiz. (sheng jiang)
The major herb is Phyllostachys, which resolves Phlegm and clears Heat. It is supported in these actions by Citrus fruit, Pinellia, Poria, Citrus peel and Zingiber. In addition, Phyllostachys, Pinellia and Zingiber promote the descending action of the Stomach Qi and, in so doing, have a normalizing effect on the digestion and assimilation of nutrients, preventing the further development of Phlegm. The other effect of these three herbs is to facilitate the Spleen in its function of sending fresh Qi to the mind and senses, aiding mental clarity. This latter action is assisted by Glycyrrhiza, Poria and Ziziphus, which tonify the Spleen and the Stomach. This formula assists in the amelioration of agitation, insomnia, lack of mental clarity and mood swings that are related to one or more of the other pathological developments in Yu syndrome. In addition, there are generally also signs of poor digestion, including loss of appetite or excessive appetite, bloating, eructation, loose stools and a thick or greasy tongue coat.
Blood stasis
Blood stasis may readily develop when the two factors of Qi stagnation and Blood deficiency co-exist. In the view of TCM, consciousness is Blood based, in that the Spirit, which resides in the Heart, depends upon an adequate supply of good quality Blood to remain tethered to the physical reality, which includes the body, the input provided by the senses, working memory, and also an awareness of the social conventions, together with empathy and consideration for others. Blood stasis, i.e. impeded movement of the Blood, with localized obstruction due to static Blood, severely disrupts these faculties. The classic formula for this type of clinical scenario is Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination) a.k.a. Blood Moving 2 Formula. It is generally prescribed together with one or more of the other formulas discussed in this section.
Formula Ingredients
Rehmannia glutinosa, root (sheng/shu di huang)
Angelica polymorpha, root (dang-gui)
Paeonia lactiflora, root (bai shao)
Paeonia veitchii, root (chi shao)
Ligusticum wallichii, rhiz. (chuan xiong)
Prunus persica, seed (tao ren)
Carthamus tinctorius, flower (hong hua)
The major herb is Angelica which has the dual actions of nourishing as well as activating the Blood, and thus epitomizes the therapeutic actions of this formula. It is supported on the one hand by Paeonia (white), Rehmannia and Ligusticum, to nourish the Blood; and on the other, by Ligusticum, Paeonia (red), Prunus, and Carthamus, to activate the Blood and dispel stasis. This formula assists patients with worsening insomnia, anxiety and poor concentration, together with signs of Blood stasis, such as dark complexion, various aches and pains (e.g. headaches), purple patches on the tongue, and a thread-choppy pulse.
STAGE 4: Injury to the Yin
Clinically, there are two types of injury to the Yin that may develop during the course of the Yu syndrome. The more severe form involves the Kidney system, while the less deep-seated condition is confined the Liver and Heart. As the Liver Blood becomes depleted and the stagnant Heat develops into Fire, the Yin of the Liver and Heart may become injured, particularly in those who are predisposed to develop deficiency syndromes. Thus, the pattern of Heart and Liver Yin deficiency may arise in these patients as a consequence of the Fire from Liver constraint, instead of Heart Fire, as discussed in Stage 2, above. The classical formula for this type of presentation is Jin Gui Suan Zao Ren Tang (Ziziphus Combination).
Formula Ingredients
Ziziphus jujuba var. spinosa, seed (suan zao ren)
Fallopia multiflora, stem (ye jiao teng)
Poria cocos, hyphae (fu ling)
Anemarrhena asphodeloides, rhiz. (zhi mu)
Ligusticum wallichii, rhiz. (chuan xiong)
Albizia julibrissin, flower (he huan hua)
Polygala sibirica, root (yuan zhi)
Glycyrrhiza uralensis, root (gan cao)
The major herb is Ziziphus seed, which nourishes the Liver and Heart and calms the Spirit. It is supported by Fallopia, Albizia, Polygala and Poria. The deficiency Heat and associated irritability are addressed by Anemarrhena and Glycyrrhiza; while Ligusticum and Albizia soothe the Liver to relieve constraint and also regulate the movement of the Qi and Blood. Polygala has the additional action as envoy to direct the actions of the other herbs to the Heart. This formula is prescribed for patients with anxiety, inability to remain asleep due to vivid and disturbing nightmares, palpitations, night sweats, restlessness and irritability, who present with a Liver-Heart Yin deficiency pattern. The clinical signs of dizziness, fatigue, a red tongue without a coat and a rapid but thready (weak and thin) pulse help to distinguish this pattern from that of Heart Fire.
Kidney Yin deficiency
In severe cases the Yin of the Kidney is affected. Due to the co-existing deficiency condition of the Heart, there may arise a pattern where the Kidney and Heart lose their normal harmonious interaction. The cooling, calming, stabilizing and grounding action of Water (i.e. the Kidney) fails to exert its influence on Fire (i.e. the Heart), leading to instability and hyperactivity within the latter. Thus, all the essential attributes of Fire, both physical and psychological, tend to become exaggerated and extreme, in the absence of the restraint that would normally be provided by Water. This particularly pertains to the Spirit, which is ‘housed’ in the Heart. We need to bear in mind that the essential features of pattern involve not only excess in Fire, but also a concomitant deficiency in Water. On the psychological level this is epitomized in the lack of effective functioning of the zhi. This term is often translated as ‘will’. However, it is a broader concept that includes the faculties of will, determination, power of concentration and long-term memory. Thus, the condition of disharmony between the Kidney and Heart may also be described as a separation of the will (in the broad sense) from the Spirit.
The classical formula used to correct this imbalance is Tian Wang Bu Xin Wan (Ginseng & Ziziphus) a.k.a. Calm the Spirit Formula
Formula Ingredients
Rehmannia glutinosa, root (sheng di huang)
Ziziphus jujuba var. spinosa, seed (suan zao ren)
Biota orientalis, seed (bai zi ren)
Salvia miltiorrhiza, root (dan shen)
Asparagus cochinchinensis, tuber (tian men dong)
Ophiopogon japonicus, tuber (mai men dong)
Codonopsis pilosula, root (dang shen)
Angelica polymorpha, root (dang-gui)
Poria cocos, fruit. body (fu ling)
Scrophularia ningpoensis, root (xuan shen)
Schisandra chinensis, fruit (wu wei zi)
Polygala sibirica, root (yuan zhi)
Platycodon grandiflorus, root (jie geng)
The major herb is raw Rehmannia, which nourishes the Kidney and Heart Yin, while also clearing the Fire from Yin deficiency. It is supported by Asparagus, Ophiopogon, Scrophularia and Salvia. These actions are complemented by herbs that nourish the Heart and calm the Spirit (Ziziphus, Biota, Salvia, Schisandra and Polygala) and herbs that tonify the Qi and nourish the Blood (Codonopsis, Poria, Angelica, Salvia). The actions of the formula’s ingredients are directed to the Heart by the envoy herbs, Polygala and Platycodon. This formula is suitable for patients complaining of over-excitability and hyperactivity, with anxiety, inability to concentrate, severe insomnia, loss of focus and self-control. There may also be palpitations, night sweats, oral ulcers, tidal fever, red tongue without coating, and a thread-rapid pulse.
Combined syndromes
As discussed above, by the time a person is experiencing a sufficient degree of distress to be motivated to seek professional help there are usually several syndrome-patterns present. The patient may have more than one of the following: Liver constraint, Qi stagnation, deficiency of the Heart, deficiency of the Spleen, Phlegm, Heat and Blood stasis. The formulas discussed below address several syndrome patterns simultaneously, in commonly occurring clinical presentations.
Mood-Uplift 2 Formula
This is an empirical formula that was developed to address the combined syndrome-patterns of:
- Spleen Qi deficiency
- Heart Blood deficiency
- Liver constraint, Qi stagnation
- Phlegm-Heat
This formula has been designed to address the common factors underlying stage 3 presentations where the initial Liver constraint leads to Heart and Spleen deficiency together with Phlegm-Heat in a complex and frequently seen clinical scenario.
Formula Ingredients
Astragalus membranaceus, root (huang qi)
Pseudostellaria heterophylla, root (tai zi shen)
Angelica polymorpha, root (dang gui)
Paeonia lactiflora, root (bai shao)
Poria cocos, fruiting body (fu ling)
Pinellia ternata, tuber (ban xia)
Phyllostachys nigra, stem (zhu ru)
Citrus reticulata, fruit peel (chen pi)
Bupleurum falcatum, root (chai hu)
Curcuma longa, tuber (yu jin)
Cyperus rotundus, rhiz. (xiang fu)
Anemone altaica, rhiz. (shi chang pu)
Polygala sibirica, root (yuan zhi)
Astragalus and Pseudostellaria are the two major herbs, which together tonify the Qi and strengthen the Spleen. Angelica and Paeonia nourish the Blood to replenish the Heart and Liver and are supported by herbs that soothe the Liver and regulate the Qi (Bupleurum, Curcuma, Peony and Cyperus). Herbs that resolve Phlegm (Poria, Citrus, Pinellia, Phyllostachys) act in concert with Polygala and Anemone to clear and calm the mind, while Polygala has the additional action of envoy to direct the actions of the other herbs to the Heart. This formula is prescribed for patients with depressed mood, anxiety and mood swings, and obvious stress factors in their lives. Signs of deficiency are also apparent, e.g. fatigue, loss of appetite, pale complexion, pale tongue, weak and/or thread pulse.
Mood-Uplift Formula
This is also an empirical formula, developed to address the following combined syndrome-patterns:
- Heart Blood deficiency
- Spleen Qi deficiency
- Phlegm clouding the mind and senses.
It is similar to Mood-Uplift 2, above, but more focused on the Heart and Spirit. It is therefore suitable for patients manifesting severe mood disturbance due to deficiency of the Heart Blood and Qi.
Formula Ingredients
Astragalus membranaceus, root (huang qi)
Codonopsis pilosula, root (dang shen)
Angelica polymorpha, root (dang gui)
Paeonia lactiflora, root (bai shao)
Ligusticum wallichii, rhiz. (chuan xiong)
Lycium barbarum, fruit (gou qi zi)
Cinnamomum cassia, stem bark (rou gui)
Fallopia multiflora, stem (ye jiao teng)
Albizzia julibrissin, stem bark (he huan pi)
Ziziphus jujuba var. spinosa, seed (suan zao ren)
Biota orientalis, seed (bai zi ren)
Poria cocos, fruit. body (fu shen)
Schisandra chinensis, fruit (wu wei zi)
Pinellia ternata, tuber (ban xia)
Curcuma longa, tuber (yu jin)
Anemone altaica, rhiz. (shi chang pu)
Polygala sibirica (yuan zhi)
The herbal ingredients essentially fall into four main groups: those that tonify the Qi and strengthen the Spleen to promote the production of Qi and Blood (Astragalus, Codonopsis, Atractylodes, Poria); those that nourish the Blood, replenishing the Heart and Liver (Paeonia, Angelica, Ligusticum, Lycium); those that calm the Sprit (Fallopia, Albizzia, Ziziphus, Biota, Poria and Schisandra); and those that clear away Phlegm and open the mind (Pinellia, Poria, Curcuma, Anemone and Polygala). In addition, Angelica, Ligusticum and Curcuma activate the Blood to address Blood stasis, while Polygala functions as envoy to direct the actions of the formula’s ingredients to the Heart. The use of Cinnamon bark is notable here as it has warming and activating actions that assist the Spleen to produce the Qi and Blood, while also assisting to activate the Blood and dispel Blood stasis. This formula is prescribed for patients with depressed mood, together with insomnia, forgetfulness, poor concentration and other signs of reduced mental functioning.
This completes the detailed discussion of some key TCM formulas that may be used in the treatment of emotion-based disorders, organized according to the paradigm of Yu syndrome. These particular formulas provide the basis for the majority of therapeutic strategies that may be devised when addressing such clinical problems. Part 3 of this series provides a more comprehensive approach to therapeutics, introducing a wider array of formulas and a return to the Five Elements system of classification. Having reached this point, it is hoped that the understanding gained from the above exposition of Yu syndrome will provide a necessary complement to the limitations of the Five Elements paradigm, and vice versa.
NOTES
[i] In this paper the terms ‘syndrome’, ‘pattern’ and ‘syndrome-pattern’ are used interchangeably. [ii] In TCM ‘fever’ is defined as a subjective sensation of being hot, or feelings of heat.BIBLIOGRAPHY
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