Dr. Rapgay is assistant clinical professor of psychiatry in the Department of Psychiatry at the Neuropsychiatric Institute, UCLA School of Medicine in Los Angeles, and director of the university’s Behavioral Medicine Program.
Acknowledgments: The author would like to thank Lidia Zylowska, MD, for her editorial assistance.
Among the Eastern medical traditions, Tibetan medicine is considered to have the most comprehensive definition, classification, diagnostics, and treatment of mental disorders. The system includes herbal, physical, nutritional, behavioral, psychological, and spiritual interventions to treat mental illnesses (such as anxiety disorders) known as “heart energy disorders” (sNing rLung in Tibetan). Although there is no evidence yet of the clinical efficacy of these treatment modalities, the Tibetan system provides an alternative model of defining anxiety disorders and of treating them from a mind-body perspective.
Tibetan medicine is gradually becoming known in the Western world, particularly for the way it defines, categorizes, and treats mental illnesses. The origin of Tibetan medicine began when Indian Ayurvedic medicine came to Tibet in the fourth century. The Tibetan kings, particularly during the seventh and eighth centuries, began to encourage the development of an integrated system of medicine by inviting Indian, Chinese, Persian, Greek, Nepalese, and Kashmiri physicians to Tibet.1 During the 11th century, the best known Tibetan physician, Yuthok Yonten Gonpo, combined the various systems of medicine into one integrated system. He presented the new system known as Sowa Ripga (science of healing) in his compilation of The Four Tantras, which serves as the core text taught to students of Tibetan medicine.2
Tibet had many medical schools before the country was invaded by the Chinese. The two most prominent schools in Lhasa, the country’s capital city, included one that specialized in monastics and another for lay trainees. Each district and monastery in Tibet would select two or more of their best students to train at these schools for 7 years. When the students graduated, they were assigned to practice in their local districts or monasteries.
In exile, the main site of Tibetan medical learning and training is in Dharamsala, India, the headquarters of the Dalai Lama. Today, Tibetan medicine is widely practiced in Tibet, India, China, Southeast Asia, Bhutan, Nepal, Mongolia, and Russia. Although Tibetan medicine is fairly new to the West, there are a number of Tibetan practitioners in Europe and the United States.3
Overall, there is very little research in the area of Tibetan medicine. The existing pilot studies on Tibetan medicine are primarily in the treatment of medical disorders,4 and no such studies address the treatment of mental illnesses. However, there is widespread recognition that among all the traditional systems of medicine, Tibetan medicine stands out in terms of its conceptualization and treatment of mental illnesses.
The Theory of Tibetan Medicine
The Tibetan medical theory is based on the three psychophysiological systems (Nepa Sum in Tibetan). The psychophysiological systems are sometimes referred to as the three basic energies or constitutions. Each system is related to different elements—air, fire, water, earth, and space—which denote unique physiological characteristics. In Tibetan language, the three systems are known as rLung, Tkripa, and Badkan. rLung, also known as the wind system, involves the activities of the air and space elements and relates to the central and secondary nervous systems. rLung is thought to include all psychological states and functions. Tkripa, also known as the bile system, involves the function of the fire and air elements and refers to function of the endocrine and vascular systems of the body. Badkan, also known as the phlegm system, involves the activities of earth and water elements and relates to the functions and activities of the lymphatic and digestive systems in the body.5
Based on Buddhist theories, Tibetan medicine identifies three driving principles that influence the three psychophysiological systems. These three principles are the instinctual forces: drives of attachment, aggression, and ignorance.5 According to Buddhist concept, the innate state of ignorance, which refers to a state of not knowing, creates tension and anxiety in the organism. Such tension leads to attempts to relieve the tension by seeking to search for stimuli and conditions that relieve the tension. The organism becomes attached to such tension-relieving stimuli.
However, such attachment to tension-relieving stimuli, can create new anxious feelings of loss, threat, etc. When the source of tension relief is threatened, the organism often responds with aggression. However, aggression then creates new forms of psychological and physiological tensions. These psychological states predispose the organism to disturbances of the three psychophysiological systems. However, additional causative factors and triggers need to be present for pathology to manifest.6
Causative and triggering factors such as imbalance in diet, nutrition, toxicity, infection, injury, and emotional and spiritual distress result in excesses, deficiencies, or disturbances in individual or multiple psychophysiological systems. When the causative factors are not treated, the psychophysiological systems exacerbate beyond their usual homeostatic functions. Consequently, other homeostatic functions are disrupted, resulting in signs and symptoms indicative of a particular disease.7
The Tibetan physician uses observation, palpation, and questioning to determine diagnosis. Observation involves urine analysis and tongue examination while palpation involves pulse examination. Questioning refers to clinical interview and history-taking. Based on the above assessment, treatment is planned. Treatment consists of behavior therapy, nutrition therapy, herbal therapy, five detoxifying treatments (nasal cleansing, enemas, purgatives, emetics, blood vessel cleansing with oral herbals), and invasive therapies.
Etiology, Diagnosis and Treatment of Anxiety Disorders in Tibetan Psychiatry
Among the ancient traditions of medicine, Tibetan medicine is widely regarded as possessing the oldest written system of psychiatry medicine that is currently practiced. The Tibetan medical texts identify two broad categories of mental illnesses—the neurotic and psychotic types.8 The neurotic types are broadly classified as “heart energy disorder” (sNing rLung in Tibetan) equivalent to general anxiety disorders, and “life-sustaining wind disorders” (Sog rLung in Tibetan) or general depression. There are four broad categories of psychotic disorders, two of which are schizophrenia and manic depression.9 In neurotic disorders, the imbalances of the rLung system do not interfere with other psychophysiological systems. However, in the case of psychotic disorders, there is wide-spread interference of other systems which, in turn, further disrupts the rLung homeostatic functions.
Etiology of Heart Energy Disorders
In Tibetan medicine, anxiety disorders (Ning–rLung in Tibetan, which means “heart energy”) are either mild or severe. Heart energy refers to the dysregulation of the autonomic nervous functions responsible for many of the anxiety symptoms. Mild heart energy disorders refer to general anxiety disorders; severe heart energy disorders refer to anxiety-related psychoses.10
Heart energy disorders are caused by distal and immediate factors. Distal causes are the primodal causes of the disorder, while immediate conditions refer to the triggers that activate the symptoms and signs of the disorder. Distal causes are the primal driving principles of attachment, aggression, and ignorance. At a primal level, heart energy disorders are predominantly caused by attachment issues. The contributory conditions that turn these disruptions into pathological entities are: (1) rLung-producing nutrition; (2) rLung-producing behavior; (3) rLung-producing emotional and psychological factors; and (4) rLung-producing toxicity, injury, etc.11
According to the Tibetan medical text The Four Tantras, heart energy disorders are marked by autonomic nervous system dysregulation, particularly in association with activity of the heart.12 The rLung system is characterized by its various functions, such as lightness, roughness, mobility. These functions manifest themselves respectively as dizziness, dry or itchy skin, and a shifting nature of symptoms such as pain.
Tibetan medicine appears to identify most of the common causes and conditions, as well as signs and symptoms, of anxiety disorders. The following conditions are thought to cause general and severe anxiety disorders: psychological and physical trauma, worrying, agitation, excessive anger, rumination, insomnia, work-related stress, excessive bleeding, excessive physical and verbal exertion, loss, poor nutrition, medical illness, and toxicity.
Pathogenesis of Heart Energy Disorder
Tibetan tradition presents a different model of looking at the pathogenesis of psychiatric disorders, and, in particular, understanding the comorbidity of anxiety and depression.
Causative factors such as psychological factors—ie, fear of specific objects, worrying—create disturbances in the rLung homeostatic functions. Failure to control the dysregulation results in further exacerbation of the central and secondary nervous systems, as well as psychological functions.13 At this phase of the pathogenesis, signs and symptoms of heart energy disorders occur. When the homeostatic dysregulation of the rLung system does not interfere with other systems, mild and moderate heart energy disorders occur. However, when other systems are disrupted, severe heart energy disorders result. For instance, when the pathological process of the rLung system interferes with the Badkan system, interference with the phlegm homeostatic functions results in a comorbidity of depression. Symptoms and signs of phlegm imbalances, such as loss of interest, or mental and physical stagnation, manifests in the patient.14
Diagnostic Procedure for General and Severe Anxiety Disorder
While the Tibetan diagnostic procedures are very different from those used in modern medicine, the procedures involve intimate human contact that might contribute towards fostering the doctor-patient relationship as well as the healing process.
The initial part of the physician examination involves analysis of the urine and the tongue. A sample of urine is collected in the early morning and the patient is required to avoid foods and behavior the night before that may impact the quality and quantity of urine. The Tibetan physician examines the urine by looking for nine characteristics of the urine, such as the size of the bubbles on stirring, rate at which they disappear, color of urine, sedimentation, presence of albumin, and rate of discoloration. For example, in heart energy disorder, the urine appears to be clear, like water, with huge bubbles that form rapidly on stirring and disappear instantly once stirring is stopped. There is minimal odor, vapor, and albumin in the urine. In the case of severe heart energy disorders with bile complications, the urine may crackle when it begins to disappear, be darker in color, and have a strong odor and albumin. In the case of phlegm complications, the urine has stagnant, small, congestive bubbles which increase on stirring, minimal odor, and a whitish hue.
Palpation, which is the next diagnostic procedure, involves palpating the right and left radial arteries of the patient with the physician’s right and left middle fingers of each hand respectively. Each of the fingertips of the physician represents and reads a specific organ of the patient. The medical texts identify specific pulse features and characteristics for each disorder. Heart energy disorder involves a rapid, fluctuating, surface pulse beat which stops completely when pressure is applied. In particular, the pulse under the physician’s index fingers, which represents the physiological functions of the area around the heart, tends to be fast and fluctuating. In the case of severe anxiety disorders, with bile or agitation complications, the pulse tends to be fast, thin, and to cease on pressure. In the case of the phlegm complications, the pulse is slow and weak, but stop under pressure.
Specific acupressure points on the body are sensitive to pressure with more sensitivity in the case of severe heart energy disorders. The main points are on the sternum between the two nipples, and the 1st, 6th, and 7th thoracic vertebrae.15
Treatment of General and Severe Anxiety Disorders
Tibetan medicine presents a very different, alternative approach to the treatment of anxiety disorders, sequentially matching levels of treatment with the severity of the disorder. After physical and clinical evaluation, treatment is planned on the basis of severity and comorbidity of the heart energy disorder. The treatment for heart energy disorders involves four stages of treatment.
Stage I: Behavioral Therapy
The treatment of choice for mild heart energy disorders involve naturopathic and nonpharmacological methods. The two main naturopathic treatments are behavior and nutrition. Tibetan medicine, unlike Indian Ayurveda, recommends behavior over nutrition as the initial therapy, since behavior involves spiritual, psychological, health, and social-related interventions.
There are three types of behavioral therapy: daily behavior, seasonal, and occasional. Daily behavior refers to daily psychological, physical, and spiritual behavior. Psychological and social behavior recommendations involve guidelines about interpersonal relationships and unhealthy behavior patterns. Spiritual behavior involves following guidelines for leading a moral and religious life. Seasonal behavior deals with adapting behavior such as conduct, exercise, activity, and dress according to seasonal changes. Occasional behavior involves regulating bodily and natural urges such as not suppressing hunger, thirst, sneezing, yawning, breathing, and sleep.
For heart energy disorders, engaging in spiritual practices that are soothing and relaxing, such as counting the breath meditation, equanimity, and visualization-based meditation, are recommended. Patients are encouraged to participate in social services and perform acts of generosity. Interventions such as cognitive restructuring, diaphragmatic breathing, and spiritual practices are recommended for adaptation to stressful and traumatic situations and conflicts, and reduction of worrying and rumination. Seasonal behavior refers to avoiding behaviors such as excessive exercising during summer, exposure to cold during winter, and eating the wrong seasonal foods.
Stage II: Nutrition Therapy
The nutrition stage involves recommendations of appropriate quantity of food to eat, nutrition for heart energy disorders, and nutrition for each of the seasons. Appropriate quantity of food for heart energy disorders involves eating three meals a day. The diet includes protein in the form of meat as well as other sources of protein, while sugar, caffeine, raw light-green vegetables and raw night-shade vegetables, should be avoided. During winter, the meals should be well cooked and herbal medicated wine is highly recommended. In the summer, high protein intake should be reduced—for instance, from red meat to white.16
Stage III: Herbal Therapy
When naturopathic approaches fail or are not adequate to treat disorders, the physician resorts to herbal therapy. Herbal therapy can be administered in nine different formulations, including syrups, powdered remedies, decoctions, and nutritional supplements. Single herbs are regarded as generally toxic and, therefore, are rarely used in traditional medicine. The use of single herbs in the US is more a Western phenomena. Tibetan pharmacopoeia consists of more than 400 formulas, with each herbal formula consisting of anywhere from 3 to 90 herbal and other ingredients.
Stage IV: External Treatment
When patients do not respond to herbal therapy, stage IV, which is external treatment, is recommended. This stage is composed of three subphases of external treatments: (1) five-detoxification treatment; (2) medicated massage, fomentation, and moxabustion with or without acupuncture; and (3) surgery. The five-detoxification treatment involves a preliminary treatment with oleation (application of medicated oil on the body) and herbal steaming, followed by the actual detoxification therapy using enemas, purgatives, emetics, nasal therapy, and blood detoxification. For instance, in the case of severe heart energy disorder, after strengthening the patient with nutritional supplements, a series of herbal enemas are administered over a period of several days or more to eliminate excessive rLung.
When the five detoxifying treatments are not effective, the second subphase of the treatment is recommended. This involves three types of treatment: massage and acupressure with herbal medicated oils, fomentation, and moxabustion with or without acupuncture. When these fail, the third subphase of treatment involving various forms of minor surgery is recommended. The medical texts depict various major surgical procedures for cataracts, rhinoplasty, and removal of any anal fistulas. However, such interventions were discontinued many centuries ago when a queen died from brain surgery.17
Depending on the needs of the patient, psychological and spiritual interventions are administered during any or all of the four stages of treatment. The psychospiritual interventions involve using the five stages of meditation. The first is sensory meditation such as basic breathing-based meditation—eg, counting the breath, focusing on inhalation and exhalation, and diaphragmatic breathing. Yantra yoga, involving specific movements regulated with breathing and concentration on the breath, may be prescribed. The second stage, cognitive meditation, involves labeling all thoughts, sensations, and emotions that arise as the patients attempt to focus on the breath. Once the patients are mindful of their own cognitive and emotional states, the third stage, analytical meditation, is recommended. This involves analyzing automatic thoughts and basic assumptions. The goal, as in cognitive therapy, is to come up with a more appropriate cognition of the situation. Once the patients have acquired the appropriate cognition of the event, they are taught the fourth stage, affective meditation, to recognize and generate the appropriate emotions. When the patients generate the appropriate cognition and emotions, they are taught the final meditation stage, visualizations, to dynamically integrate the sensory, cognitive, and affective processes.18
The Tibetan system provides an alternative model of diagnosing and treating anxiety disorders that integrates medical, behavioral, psychological, and spiritual approaches of managing anxiety disorders. The system seeks to include patients in their diagnosis and treatment by acknowledging the patient’s complaints, incorporating them with the physician’s medical diagnosis, and clarifying treatment options for both. This method provides a new way of conceptualizing the role of mind-body medicine in anxiety disorders and creates a framework for assessment and treatment of anxiety disorders to faciliate the doctor-patient relationship beyond the medical model. PP
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