COMMONLY USED CHINESE HERB FORMULAS FOR THE TREATMENT OF MENTAL DISORDERS

by Heiner Fruehauf


Introduction

The concept of an inseparable bodymind continuum is one of the main characteristics of Eastern thought. In classical Chinese medicine, therefore, mental activity has always been considered to be inseparable from bodily functions, and mental diseases were generally not treated differently from any other disorder. The Chinese term 'yuzheng' (depression), for instance, refers to stagnation on both a physical and mental plane, and is usually addressed with the same diagnostic and therapeutic means as diseases that would be considered to have entirely physical origins in the West.

It is perhaps this absence of a body/mind dichotomy that is at the core of Chinese medical theory and practice. As described in the classic sources of Chinese scientific thought, such as the Yijing (Book of Change ), the Daodejing, or the Neijing (Inner Canon of the Yellow Emperor), ancient Chinese observers of life always postulated the existence of a primordial One. From this prenatal entity, they thought, emerged two polar aspects which interact in a process of constant flux. This concept that all differentiation originates from a single source is one of the main messages of the Daodejing, the Taoist text which first coined the classic statement: "The Dao produced the One, the One produced the Two, the Two produced the Three, and the Three produced the Myriad Things."
Every thing and every phenomenon, according to Chinese medical theory, can be analysed with this one-two-three-many grid of categorisation. In the one space time continuum we live in, for instance, there are the two dominant celestial bodies sun and moon, surrounded by myriads of other stars; there is humankind as a whole, differentiated into male and female; and there is the individual human being, consisting of material form (body) and immaterial qi which in its highest form is called 'shen' - the conscious mind.
Although most scholars and practitioners of Chinese Medicine agree that the body (xing) and the mind (shen) are interdependent entities, there has been much discussion about the concrete nature of this relationship. In the People's Republic of China, discussions of this nature are often influenced by political considerations. Most mainland scholars, acutely aware of the Marxist agenda of their superiors, usually draw a distinct line between religious 'idealists' and scientific 'materialists' when it comes to body/mind related topics. Xunzi, the ancient philosopher who had said that "when there is a body, there can be a mind," has been hailed in contemporary books as a model of "materialist and thus scientific" thinking.

This increasing emphasis on the structural aspects of the body, however, goes back much further than the establishment of the People's Republic of China in 1949. If we take a look at Chinese medical history, it becomes evident that a gradual shift from the immaterial yang aspects to the structural yin aspects of diagnosis and treatment has been taking place throughout the last two millennia.
In the original source texts of Chinese medicine, represented by the Book of Change, the Daodejing, and the Inner Canon, yin and yang are depicted as equal forces, yet the rising yang stands out as the conceptual landmark from which the various phases of the cyclical process of transformation are assessed. According to the Inner Canon, for instance, the energetic network that is referred to as the Heart governs the activities of all other organs: "The Heart is the ruler of all the other organ systems, and it is here that the power of the conscious mind is created. If the ruler is bright, there will be peace below ... If the ruler is dim, however, the twelve organ systems will enter a state of crisis, resulting in channel obstruction and severe injury to the physical body.
 

Following the formative period of Chinese medicine, a gradual yet obvious shift of attention toward the structural (yin jing) aspects of the body occurred. Diagnostic procedure, for instance, changed from sensing the shen, i.e. the energetic glow of the face and eyes (Inner Canon, c. 200 B.C.) to the more hands-on yet still qi oriented method of pulse palpitation (Shanghan Lun, c. 200 A.D.), to a primarily structurally oriented system where tongue shape and colour (18-19th century) or X-ray pictures (PRC) are the main means of diagnosis. The same is true for the therapeutic realm where the ancient and entirely qi based modalities of qigong and acupuncture were gradually replaced by herbal medicine, a system that is based on the administration of material substances. Within the developing field of herbal medicine moreover, the early emphasis on yang herbs such as Rou Gui (Cortex Cinnamomi Cassiae) and Fu Zi (Radix Aconiti Carmichaeli Praeparatae) gave way to a growing preference for yin herbs such as Di Huang (Radix Rehmanniae Glutinosae), or dense jing tonics derived from animal materials.
But no matter what school of thought they adhere to, scholars of Chinese medicine usually agree that the mental and physical aspects of the human body are engaged in a process of constant movement and transformation. Any physical process is believed to have mental implications and vice versa. The connecting entity is qi, which can be differentiated into physical and mental qi only academically. In general, mental energy (shen qi) is simply regarded as a more refined form of physical energy (jing qi). Traditional treatment principles for mental diseases, therefore, do not fall outside the realm of standard diagnostic and therapeutic procedure. Even in contemporary China, mental patients usually visit doctors who specialise in "internal medicine," that is the treatment of organ disorders with Chinese herbs, minerals, and animal materials.
The therapeutic focus tends to be on the restoration of uninhibited qi flow, since unbalanced emotions first affect the qi before they influence the physical structure of the body. Since chronic qi stagnation eventually results in the formation of structural pathologies such as blood stasis or phlegm coagulation, the modalities of blood moving and phlegm purging are standard methods to treat the more chronic types of mental disorders. In addition, Chinese physicians often address various types of deficiencies. The following is a brief overview of traditional and contemporary approaches to the most common mental disorders.

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DEPRESSION
In classic Chinese medical texts, depression is labelled yuzheng (depression syndrome) and refers to a wide array of symptoms which are usually attributed to stagnant qi. Unhappy emotions are generally believed to be the prime cause for stagnant qi. This psychosomatic aspect of qi has been emphasised in sources that go back at least as far as the Inner Canon, which pioneered the classic statement "In a patient full of grief and sadness, the qi becomes depressed and does not move"3. Later on, the 7th century medical compendium, Zhubing Yuanhou Lun (A Discussion of the Symptoms and Origins of Disease), devoted an entire subchapter to the pathogenesis and treatment of 'knotted qi', explaining that "the knotted qi disease is caused by grief and worry."4
The term 'yu' describes symptoms of mental depression and maybe the beginning stages of physical manifestation, such as discomfort in the sides of the body or the sensation of a lump in the throat. At a more advanced stage, it can incorporate severe symptoms of phlegm and blood stagnation such as tumours or other types of accumulations which have formed due to a chronic state of imbalance.
Since the traditional Chinese concept of health is closely tied to the presence of an uninterrupted energy flow, depression - the manifestation of obstructed or 'depressed' qi flow - has always been taken very seriously by Chinese physicians. Several influential medical scholars even asserted that all disease has its origin in the depression of the mental and physical flow continuum. The Song
dynasty physician Chen Yan, in his landmark work, Sanyin Ji Yi Bing Zheng Fang Lun (Discussion of Illnesses, Patterns, and Formulas Related to the Unification of the Three Aetiologies), first singled out the depression of the seven emotional affects (joy, anger, anxiety, worry, grief, apprehension, and fright) as a major aspect of clinical pathology. This theory culminated in the formation of an entire school of medical thought, represented by the six depression approach (depression of qi, blood, dampness, phlegm, fire, and food) authored by the 15th century physician Zhu Danxi. Zhu created the influential statement "If qi and blood exist in abundance and harmony, a person will not get sick. Once there is depression, all kinds of diseases will start to evolve. Therefore, all of the body's diseases are caused by depression."
From this rich tapestry of medical thought and clinical experience evolved a prolific reservoir of herbal formulas that are frequently used in the treatment of depression. Not surprisingly, most of these formulas regulate various aspects of the Liver network. The Liver is in charge of the harmonious distribution of qi - the flow organ of the human body/mind complex; as the Chinese pictogram for Liver indicates (gan*character will be inserted: straight), it strives to spread upward and outward and resents being suppressed. The Liver channel, moreover, runs deep through the sexual organs, and another area associated with the realm of the subconscious - dream activity - is generally attributed to the Liver network. All of these factors indicate the close conceptual affinity of the Liver system to the hidden realm that Western culture accesses through psychotherapy. "All depression," the 18th century primer Zabing Yuanliu Xizhu (Wondrous Lantern Peering into the Origin and Development of Miscellaneous Diseases) thus declares, "can be classified as a Liver disease. The origin of this disorder is excessive worrying. 'Yu' (depression), in other words, is a general term for diseases that have originally been caused by emotional problems. It is primarily a qi disorder, and is generally treated as such. After a long time, however, 'qi depression' may cause a) blood stasis, b) fire depression, c) damp depression, d) phlegm depression, or e) various levels of deficiency. Treatment strategies for chronic depression thus may have to take these components into account.

At the Institute for National Medicine and Pharmacology in Heilongjiang Province, Dr. Ma Longqi used a combination of the traditional shaoyang formulas Xiao Chai Hu Tang (Minor Bupleurum Decoction), Da Chai Hu Tang (Major Bupleurum Decoction) and Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction), to treat 307 patients who had been officially diagnosed as suffering from 'neurasthenia', a term that is frequently used in China to describe depression.

The formula he used,was administered in granulated form. At the end of the study a general effectiveness rate of 96.7% was reported, with a markedly improved rate of 56%7. 

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MENTAL DISEASE

In Western clinical practice, the diagnosis and treatment of mental disease tends to be highly differentiated. Chinese physicians, however, have often discussed the various manifestations of mental disease under the same heading. Nonetheless, treatment strategies are complex, mostly consisting of the three aggressive methods of purging, flushing phlegm, and moving blood.
Due to the obvious discrepancy between the modern and the traditional assessment of mental disease, contemporary Chinese researchers appear to be divided about the best way of conducting scientific clinical trials in this field. Some have opted to set up their trials according to Western diagnosis, accepting only cases that have been officially diagnosed as suffering from obsessional
neurosis, or psychogenic psychosis, or schizophrenia. Others have opted to conduct their clinical studies according to their own clinical experience, using a single "mental formula" for all kinds of disorders, including depression or schizophrenia which are discussed elsewhere in this article.

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SCHIZOPHRENIA
Schizophrenia has always been looked upon as a 'strange' disease by Chinese physicians. Over the last hundred years, many self-declared masters of difficult diseases have taken up the challenge. Among them were Wang Qingren, the 19th century renegade physician and representative of the clinically extremely important blood moving school, and Zhang Xichun, the eminent 1920's physician who was known for his phlegm oriented approach to difficult diseases. Wang designed yet another blood moving formula for the treatment of schizophrenia, namely Dian Kuang Meng Xing Tang (Awaken from the Dream of Madness Decoction), while Zhang created Dang Tan Tang (Flushing the Phlegm Decoction). By primarily addressing phlegm and blood stasis, both of these approaches are representative of the traditional treatment of schizophrenia and 'strange disorders' in general.

In traditional texts, schizophrenia is usually referred to as 'madness syndrome' (dian kuang). This term is ambiguous, since it really includes two opposite conditions, namely dian (depression) and kuang (mania, wild and crazy behaviour). Kuang often refers to the violent eruption of a mental condition, which usually can be controlled rapidly by the application of purging methods33. The high status of purging methods among the therapeutic modalities of Chinese medicine reflects the ancient concept of an evil spirit possessing the patient, which needs to be aggressively expelled from the body. Schizophrenia, however, is a complex disorder which can have a multiplicity of causes. Prolonged purging, favoured in many contemporary Chinese case studies, is thus not necessarily the correct treatment for patients who have been diagnosed with schizophrenia by a Western physician. The contemporary manual, Xiandai Zhongyi Neike Xue (A Modern Handbook of TCM Internal Medicine), appropriately emphasises the necessity of broadly distinguishing between the categories of yang type schizophrenia and yin type schizophrenia, that is between the 'wild' manic type and the depressed type.
Yang type schizophrenia is characterised by symptoms of hallucinations (auditory, olfactory, or visual hallucinations; discussions with imaginary partners), delusions (paranoia, jealousy, hate, guilt, religious delusions etc.), bizarre behaviour (strange clothing, strange movements, tendency to attack
others, repetitious speech or actions), and irregular thought patterns (answers do not match questions, sentences are not logically connected, constant change of topics, etc.).

The base formula suggested in the manual is a modified version of Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction), to be taken daily for 60- 90 days.

Yin type schizophrenia is characterised by symptoms of dull emotional expression (no change in facial expression, dull eyes, decrease in self-initiated movements, inability to love etc.), reduced intellectual activity (talks little, sentences have little content or are unfinished, slow response), and decrease of general awareness (lack of hygiene, loss of concentration, decreased sex drive, loner behaviour, low excitability, disregard of social codes). The suggested base formula is a modified version of Si Ni Jia Gui Tang (Frigid Extremities Decoction plus Cinnamon Twig), to be taken for 60-90 days. Despite the high dose of Fu Zi (Radix Aconiti Carmichaeli Praeparatae), no side effects were observed in extended clinical trials34.

 One of China's leading schizophrenia specialists, Dr. Qiao Yuchuan, prescribed his formula to 415 schizophrenia patients. The standard treatment time was two weeks, with an expected occurrence of diarrhoea that was not to be treated. After two weeks, the prescription of Gui Pi Tang (Restore the Spleen Decoction) or other harmonising formulas was advised.

Of 415 participating patients, 330 were reported cured, 42 improved, 2 without result, and 41 stopped the treatment before completion. The overall effectiveness rate was 98.6%35. In a consecutive study conducted by the same research team employing three differentiations of this formula (Schizophrenia Formula No.1 for depressed Liver qi and fire flare-up, Schizophrenia Formula No.2 for blood deficiency and phlegm fire, and Schizophrenia Formula No.3 for excess heat in the yangming channels), similar results were achieved. Of 500 patients (229 males, 271 females, all ages, disease histories ranging from several months to 30 years), 401 were reported cured, 93 improved, and 6 without result36 .

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ANXIETY DISORDERS

The modern term anxiety disorders encompasses a group of mental illnesses in which symptoms of anxiety prevail. Anxiety disorders are fairly common, affecting roughly four percent of the population in North America. Western medicine distinguishes between generalised anxiety disorder (anxiety neurosis), panic disorder, phobia, post-traumatic stress disorder, and obsessive-compulsive behaviour. All of these disorders involve the vegetative nervous system in an obvious manner. Patients tend to be extremely tense and nervous. During acute attacks involving fear and/or panic there may be breathing difficulties, palpitations, dizziness, nausea, abdominal distention, or a variety of other symptoms. Anxiety disorders are frequently accompanied by sleep disturbances such as insomnia or excessive sleeping.
From a Chinese perspective, symptoms of anxiety always call for methods that 'quieten the spirit' (anshen, dingshen, ningshen). Almost all formulas designed for this disorder thus employ sedating materials, such as the downbearing minerals Ci Shi (Magnetitum) and Long Gu (Os Draconis). In addition, differentiated approaches are used to address the underlying cause for spirit unrest, such as blood deficiency or phlegm obstruction.
 

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NEUROTIC INSOMNIA

Insomnia is probably the most frequent symptom accompanying neurotic disorders. In Chinese medicine, it is again the sedating aspect which plays a predominant role in clinical therapy. A modern formula with the programmatic name, Zhen Xin An Shen Tang (Sedate the Heart and Calm the Spirit Decoction), was used for 157 cases with sleeping disorders. All participating patients reported one of the following symptom complexes: extreme difficulty in falling asleep, less than three hours of sleep per night, loss of effectiveness of sleeping pills; or waking up early without being able to go back to sleep, sleeping only 2-3 hours a night, or inability to fall asleep at all during the night. The formula used was a combination of ingredients that are primarily known for their sedating affect. Patients were instructed to boil the materials twice, take the weaker medicinal liquid obtained from the second boiling in the afternoon or in the evening, and drink the first boiling right before going to bed. If there was a tendency to wake up early, patients were advised to take the first boiling before going to bed, and the second boiling after waking up. After 3 days of treatment, progress in the 157 participants was evaluated in the following way: 98 markedly improved, 55 improved, and 4 without results38.

A similar approach was employed by the designers of a herbal sleeping pill, which was formulated at the height of Chinese-Western combination therapy during the late 1970's. The experimental Anmian Wan (Sleeping Pills)were used.  Patients were advised to take 2-3 pills one hour before going to sleep. Of 453 cases, the treatment was considered effective (the patient could sleep within 30-60 minutes of taking the pills) in 361 patients, and not effective in 92 patients39 .

Since Wang Qingren's contribution to Chinese medicine, there has been a heightened awareness of the role of blood stasis in chronic diseases. Contemporary Chinese clinicians thus put great emphasis on blood moving herbs such as Dan Shen (Radix Salviae Miltiorrhizae) and formulas such as Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction) in the treatment of insomnia. In 1986, Dr. Xie Yong et. al. published his experience with the blood moving approach to insomnia in the article, 'A Report of Treating 240 Insomnia Cases With Blood Movers.' Of 240 cases (115 males, 125 females; 120 neurosis patients, 120 schizophrenia patients; disease histories ranging from 3 months to 15 years, with an average of 3 years), 81 were reported markedly improved, 87 improved, and 72 without satisfying results. The treatment period was 20 days. The best effects were observed in neurasthenic patients.

Another example for this approach is the experimental research formula, Huo Xue Mian Tong Tang (Move the Blood and Bring About Sleep Formula). The remedy was tried on 112 patients suffering from severe insomnia, which was defined as only 1-3 hours of sleep per night, accompanied by symptoms of dizziness/headache, memory loss, panicky emotional state, shortness of breath or fatigue. At the end of the study, 30 were reported cured, 45 markedly improved, 29 improved, and 8 without result. The general effectiveness rate was assessed at 93%. The shortest
treatment time was 1 week, the longest 8 weeks, with an average of 3 weeks .

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