Dr. Zylowska is resident in training in the Department of Psychiatry at the UCLA Neuropsychiatric Institute in Los Angeles, and a former fellow at the UCLA Center for East-West Medicine.
Dr. Hui is professor of clinical medicine in the Department of Medicine and director of the Center for East-West Medicine at the UCLA School of Medicine in Los Angeles.
Acknowledgments: The authors would like to thank Regina R. Chinsio and Mai K. Ho for their intellectual contribution and assistance in preparing this manuscript. They also thank the Oppenheimer Family Foundation for its generous support of their work, including preparation of this article and Dr. Zylowska’s fellowship.
An increasing number of patients are using complementary and alternative medicine for both medical and psychiatric conditions. Do our patients know something we do not? Can clinicians and scientists in search of novel treatment strategies benefit from understanding the principles of other healing traditions? This article introduces the general framework of Chinese medicine and outlines its view of emotions in health and disease. The article briefly describes Chinese medicine’s approach to patients with anxiety, reviews available research on acupuncture in the treatment of anxiety disorders, and suggests potential benefits of incorporating Chinese medicine into clinical practice and research.
Oriental medicine and its most representative member, Chinese medicine, is a collection of ancient healing traditions with over 3,000 years of use and refinement in the Far East, predominantly China, Japan, and Korea. Chinese medicine represents a complete system of healing that, for centuries, evolved independently of Western cultural influences. In contrast to Western medicine, which describes the human body in terms of anatomical organs and structural and quantitative markers of disease, Chinese medicine conceptualizes the human body as a functional and energetic system and describes illness as an imbalance within these systems. Chinese medicine has its own conceptual framework, unique diagnostic methods (eg, tongue and pulse diagnosis), distinctive diagnostic formulations (eg, liver qi stagnation), and specialized treatment methods (eg, acupuncture, herbal medicine, massage, and qigong).
Although there is no separate discipline of psychiatry in Chinese medicine, this medical tradition has long recognized the importance of mental and emotional factors in health and disease, and it has been used to treat psychiatric illness. The theoretical, cultural, and linguistic differences between Chinese and Western medicine make it challenging to integrate the two systems of healing, yet such endeavors may yield improved clinical and research results.1 In this review, we outline the general framework of Chinese medicine, discuss the role of emotions in health in Chinese medicine, introduce some therapeutic approaches to emotional distress, and review available scientific evidence on treatment of anxiety disorders using acupuncture. For further information on psychiatry-related topics and Chinese medicine, the reader is referred to other, more comprehensive discussions.2-6
History of Chinese Medicine
Despite dominance of the Western medical paradigm in most countries, Chinese medicine remains a vital medical tradition—more than one fourth of people worldwide use it for promotion of health and treatment of disease. This healing system underwent a revival in the 1950s when the Chinese government began to support the development of Chinese medicine and encourage its integration with modern medicine. Over the last several decades, researchers in China and throughout the world have applied modern scientific techniques, including molecular biology, immunology, and pharmacology, to elucidate Chinese medicine theory and treatment methods. Modern ways of applying Chinese medicine techniques, such as laser acupuncture and using herbs to lower side effects of chemotherapy, have emerged. In the Western world, Chinese medicine remained obscure until President Nixon’s trip to China in the 1970s—a trip that spurred American interest in Chinese medicine, particularly acupuncture.7
The research evidence generated over the last several decades has revealed the role of the endogenous opioid system in acupuncture analgesia and suggested involvement of autonomic and neuroendocrine pathways in its other applications.8-12 Of relevance to psychiatry, studies have implicated changes in serotonergic, noradrenergic, and dopaminergic neurotransmitters with acupuncture, and two recent magnetic resonance imaging studies demonstrated acupuncture modulation of brain regions including the limbic system.11,13
Brief Overview of Chinese Medicine Theory
The Chinese medicine paradigm represents a comprehensive collection of theory, observations, and insights from consecutive generations of traditional Chinese physicians. More recently, researchers and physicians have proposed modern descriptions of ancient concepts. Chinese medicine framework is rooted in principles of energy-matter transformation, cyclical movement, relativity, and interdependence in nature. Within this framework, the human body is described in terms of functional and energetic properties and represents a “microcosm” with laws, rhythms, and properties analogous to those observed in the natural environment. Consequently, Chinese medical terminology uses analogies and metaphors borrowed from nature to describe complex physiological processes of the human body. For example, mania may be described as “excess of heat” or “fire,” while processes characterized by growth, movement, or transformation, may be considered “wood” or “spring” properties. At first glance, the metaphoric language of Chinese medicine may appear archaic and nonscientific, deterring one from delving into the theory of Chinese medicine. However, once Chinese medicine theories are tested clinically and through research performed, a better appreciation of its effectiveness, complexity, and internal consistency will be developed.
The major components of the Chinese medical theory include: (1) the concept of interdependent and mutually-balancing components of the human body as represented by the yin and yang theory and the five element/phases theory; (2) the concept of the energy-matter communication network as represented by the meridian system, qi, and the vital substances theory; (3) the description of human anatomy as based in functional systems as represented by the zang fu organ network; and (4) the individualized description of the illness process and the body’s response to it as represented by the zheng pattern diagnosis.14 In modern terms, Chinese medicine has been said to embody a holistic, systemic view of the human body that emphasizes the inseparable nature of body/mind/spirit, the centrality of homeostatic balance and self-healing, and the importance of energetic flow. Akin to emerging trends within behavioral medicine, psychoneuroimmunology and psychosomatic disciplines, Chinese medicine has long recognized environmental, psychosocial and spiritual factors in health and disease (Figure).15
The Unity of Mind and Body
The dualistic view of soma and psyche dating back to the French philosopher, René Descartes, has shaped Western medicine’s division between physical and mental etiologies of illness. In contrast, the Chinese medicine framework considers soma, psyche, and spirit to be fundamentally intertwined in structure and function. The interaction is bidirectional and circular: cognitive and emotional factors affect physical aspects of the body just as much as the physical aspects affect mental and emotional expression. This dynamic relationship permeates Chinese medicine and can be exemplified by the relationships within the zang fu organ network and the vital substances theory.
The organ network is primarily composed of five interdependent systems: the heart, liver, spleen, kidney, and lung systems. Despite similarities in names and some functions, the organ network of Chinese medicine should not be equated with Western anatomical terms since each Chinese medicine organ network simultaneously encompasses a variety of physiological and mental/emotional characteristics. For example, the Chinese medicine liver network includes certain functional aspects of the hepatobiliary, musculoskeletal, genitourinary, hormonal, and nervous systems. Additionally, the liver network plays a role in distribution and movement of blood and overall emotional expression. Each organ is believed to have special affinity for a particular emotion or cognitive ability: liver—anger; heart—joy/happiness; spleen—pensiveness or over-thinking, kidney—fear/fright, and lung—sadness and grief.
The vital substances theory represents another level of mind-body integration within Chinese medicine. Jing, blood, fluids, qi, and shen are the main physiological substrates that form a spectrum from the more material (jing) to the more energetic/metaphysical (shen). Just like the organ network, the substances are mutually dependent and underscore the inseparable nature of somatic/biological and psychological/ energetic aspects of a person. Shen, often translated as the “spirit” has a special importance for mental-emotional disorders and has been described as the composite of all mental activities and characteristics, including thinking, consciousness, insight, intelligence, cognition, wisdom, formation of ideas, sleep, and memory.5 In Chinese medicine, the state of a person’s shen is a measure of their overall psychological well-being and vitality, and thus, most psychiatric disorders involve shen disturbance.
Emotions in Health and in Illness
In Chinese medicine, health results from adequate and optimal interaction between the somatic, psychological, and energetic aspects of the person. An appropriate and balanced flow of natural emotional states is necessary for health maintenance. Internal and external factors (stressors) challenge the body’s regulatory mechanisms and, if overwhelming, illness may result (ie, yin-yang and the organ network are out of balance). This view is analogous to the model of stress adaptation,16 in which various stressors may overstrain the homeostatic system and lead to illness. However, the way stressors are defined in Chinese medicine differs from in Western medicine. In Chinese medicine, excessive emotions are themselves considered the main internal stressors while extreme environmental, climate-related factors, infections, trauma, exertion, and lifestyle excesses are the main external stressors.
Within the organ network, prolonged and excessive expression of a particular emotion is thought to first affect (“injure”) its corresponding organ. However, due to interlinking of individual organs, any abnormal emotional expression can lead to imbalance in the entire system. Likewise, any of the external factors can lead to progressive dysfunction of the organ network that, once dysregulated, can produce abnormal emotional states.
The conceptual framework outlined above leads to a novel understanding of etiology and treatment strategies for both medical and psychiatric symptoms. In Chinese medicine, physical or psychological trauma, poor diet, exposure to extreme cold or heat, infections, and excessive or repressed emotions can lead to both physical and mental/emotional symptoms.
Diagnosis of Illness and Therapeutic Principles
The general Chinese medicine approach in any illness involves diagnosing and correcting the imbalance within the meridian system, the zang fu organ network, and the vital substances. The treatment methods usually include acupuncture, moxa, massage (tuina and acupressure), herbal medicine, and qigong exercises to restore flow and balance.
In making a zheng pattern diagnosis, Chinese medicine physicians pay close attention to the constellation of each patient’s emotional and somatic complaints, his or her preferences (dietary, climactic), constitution (genetic and postnatal contributions), and prevailing emotional expression and coping style. The history is supplemented with Chinese medicine pulse and tongue diagnosis.6 Although often called the “pattern” or “syndrome,” the zheng diagnosis is not merely a collection of symptoms, but reflects the location and stage of pathogenesis created by interaction between the stressor or pathogen and the body’s defense and regulatory systems. The diagnosis also aims to identify the global character of the conditions as either predominantly excessive or deficient within the overall yang (activating or upregulating) or yin (preserving and downregulating) processes.
The interaction of parasympathetic (yin) and sympathetic (yang) nervous systems can serve as a simplified example of yin-yang character in physiological processes. As a generalization, anxiety states can result from both excess of yang or deficiency of yin, but mixed excess-deficiency states are often observed. Since zheng pattern diagnosis reflects the individual characteristics of the patient as they influence illness manifestation and progression, patients with the same Western diagnosis may present with different zheng patterns. Likewise, patients with different Western diagnoses may present with the same zheng pattern.
Once a Chinese medicine practitioner makes a diagnosis, he or she will typically use acupuncture, massage, and herbal medicine together. As the treatment is applied, the practitioner monitors the changing manifestations of a zheng pattern to assess success of the treatment and to adjust the strategy if needed. Both herbal medicine and acupuncture are used according to a two-level treatment approach: (1) to relieve the acute physical and psychological symptoms (eg, insomnia, heart palpitations, acute anxiety, or gastrointestinal distress); and (2) to correct the patient’s unique underlying disharmony that has led to the somatic and psychological symptoms. In anxiety states, “shen calming” herbs such as semen zizyphy spinosae are commonly used, usually combined with other herbs to match the patient’s unique zheng pattern.
An acupuncture point found on the lower arm nei guan (pericardium 6) and a point located between the eyebrows, known as “yin tang,” are frequently used in anxiety states. Depending on each patient’s individual constellation of symptoms, other points are selected. Points on the external ear (auricular acupuncture) have also been used for psychological disorders. The acupuncture points can be stimulated by twisting the needle with low-current electricity, laser, or heat (moxa).2,11 Regional or localized massage (acupressure) can be done by the practitioner or taught to the patient as a self-help technique. Qigong (slow movements, breathing, and meditative exercises), which is thought to harmonize the spirit/mind/body unity, is frequently recommended to patients, especially if psychological distress is present.
Chinese Medicine and Psychiatric Disorders: Does It Work?
A paucity of research studies of Chinese medicine and psychiatric disorders exists. Furthermore, much of the available research studies in this area are published in Asian languages and/or have methodological problems limiting interpretation of their results. Among Chinese medicine modalities, acupuncture is by far the most studied. Two recent publications reviewed acupuncture trials for psychiatric conditions3,17 including depression, anxiety, schizophrenia, and substance abuse. One study investigated computer-controlled electroacupuncture in a mixed group of 104 patients with “neurotic depression,” generalized anxiety disorder, neurasthenia, and obsessive-compulsive disorder. Results indicated that computer-controlled electroacupuncture significantly reduced the total scores on the Hamilton Rating Scale for Depression and the Self-Rating Anxiety Scale.17 Another study compared electroacupuncture and amitriptyline in the treatment of depression. The authors reported similar significant improvement in depression scores in both treatment groups after 6 weeks, but superior improvement in clusters of anxiety, somatization, and cognitive disturbance with acupuncture.18 Supporting a common clinical observation, other research has shown that acupuncture has sedative effects19 and that auricular acupuncture can be used for anxiety.20, 21
In evaluating Chinese medicine research, it should be noted that most available studies have used Western diagnoses and standardized acupuncture protocols. However, Chinese medicine relies on designing an individualized treatment to address each patient’s unique imbalance and the omission of zheng pattern diagnosis (often diverse in patients with the same Western diagnosis) creates a sub-optimal model for testing Chinese medicine efficacy. In the future, attention to these factors when designing studies may yield more reliable results and provide new insights into diagnosis and treatment strategies.
Chinese medicine has a long history of use and represents a medical paradigm rooted in the philosophy of mind-body integration, a perspective that is also emerging through psychosomatic research and advances in neurobiology. The framework of Chinese medicine generates new ways to approach psychological and somatic distress, which may lead to novel ways of understanding etiology, prevention, and treatment of psychiatric illness. Some research studies have already implicated the ability of acupuncture to affect the central nervous system, and they suggest potential benefits from further research and clinical integration of conventional and Chinese medicine. The field of anxiety disorders with its long-standing recognition of interacting physiological and psychological states presents an opportunity for such exploration. PP
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