Sulpiride

Until this century and the adoption of Western medical divisions, [1] there was no specifically psychiatric specialty within professional Chinese medicine. Rather, psychiatric disorders were simply lumped in with the so-called miscellaneous diseases (za bing) of traditional Chinese internal medicine (nei ke) along with such somatic complaints as impediment, wilting, wasting and thirsting, headache, and abdominal pain. To make matters worse, many premodern clinical manuals of Chinese medicine only listed two specifically mental-emotional disease categories. Like many things within Chinese medicine, these two psychiatric disease categories are a yin-yang dichotomy and, as such, are meant to encompass the full spectrum of psychiatric disorders. However, because Western readers see only two recognizable psychiatric disease categories among dozens of other more somatic traditional Chinese disease categories, some have assumed that Chinese medicine pays scant attention to psycho-emotional complaints. In my experie nce, this is far from the case, and, if one correctly understands the overarching importance of Chinese medicine's two most basic psychiatric disorders, then almost any modern Western psychiatric complaint can be diagnosed and treated with Traditional Chinese Medicine.

These two traditional Chinese psychiatric disease categories are withdrawal (dian) and mania (kuang) . As stated above, withdrawal and mania are a yin-yang pair of conditions which can either exist separately or alternate back and forth between the two. Withdrawal refers to a torpid, flat, depressed affect with a tendency to taciturnity, uncommunicativeness, and solitariness. It may also include incoherent speech, a lowering of mental faculties, and even syncope and coma. Mania refers to an agitated, excited affect accompanied by inappropriate anger and/or laughing, mental, physical, and emotional restlessness, etc.

The first mention of withdrawal in the Chinese medical literature appears in the Nei Jing (Inner Classic). Both the Su Wen (Simple Questions) and Ling Shu (Spiritual Axis) refer to "withdrawal disease," "withdrawal and epilepsy," "bone withdrawal disease," and "vessel withdrawal disease." Zhang Zhong-jing's Jin Gui Yao Lue (Essentials of the Golden Cabinet) speaks of "withdrawal and dizziness," while Chao Yuan-fang mentions "wind withdrawal" and Sun Si-miao mentions "withdrawal evils." As for the term "mania," it predates the Chinese medical literature, showing up in such early Chinese classics as the Shang Shu (Book of Shang) and Huai Nan Zi (Master Huai Nan). The Su Wen (Simple Questions) refers to "reversal mania" and "fright mania." Chao Yuan-fang discusses "wind mania." The first use of the compound term "withdrawal and mania" is in the Ling Shu (Spiritual Axis). By the Ming dynasty, withdrawal, mania, and epilepsy were considered the three major manifestations of essence spirit or psychiatric disease.

Chinese disease causes & disease mechanisms

In Chinese medicine, stirring or movement (which includes mental stirring, verbal stirring, and physical stirring) is categorized as yang, and stillness is categorized as yin. Therefore, mania, which is characterized as excessive stirring and movement, is categorized as yang, while withdrawal, which is categorized as abnormal stillness, is categorized as yin. In the Su Wen (Simple Questions), it says, "All agitation and mania pertain to fire." In "Difficulty 20" in the Nan Jing (Classic of Difficulties), it says, "Double yang leads to mania; double yin leads to withdrawal." Later doctors built upon this early nosological framework in further elaborating the disease causes and mechanisms of withdrawal and mania.

In the Yuan dynasty, Zhu Dan-xi said: Withdrawal is categorized as yin, while mania is categorized as yang...Mostly it is caused by phlegm binding within the heart and chest.

In the Qing dynasty, Ye Tian-shi said: Mania is due to great fright and great fear. The disease is in the liver, gallbladder, and stomach channels. These three yang [organs] combine and ascend and upbear. Therefore, fire blazes leading to phlegm surging. Hence the orifices of the heart become blocked and obstructed. Withdrawal is due to accumulation of worry and accumulation of depression. This disease is in the heart, spleen, and pericardium. These three yin [organs] seek shelter and do not diffuse. Hence qi depression leads to phlegm confounding, and the spirit mind becomes obscured.

In general, we can say that withdrawal is either due to the clear qi not being upborne and, therefore, the spirit brilliance not being constructed or some evil causing lack of free flow of the qi and/or blockage of the heart orifices. Heart-spleen dual vacuity and spleen-kidney yang vacuity are the two main mechanisms for nonconstruction of the spirit brilliance. Liver depression due to unfulfilled desires may cause non-free flow of the qi and, therefore, inhibition of the qi mechanism which may also manifest as inhibition of the spirit will. When it comes to blockage of the heart orifices clouding and confounding the spirit, phlegm and blood stasis are the main culprits. Mania, on the other hand, is primarily due to the heart spirit being harassed by some sort of evil heat or fire. This may be depressive heat, phlegm heat, yang ming replete heat, or vacuity heat. However, some Chinese sources say that blood stasis may also cause mania. In this case, heat has damaged the blood and the blood has become static .

Although some Chinese textbooks list a blood stasis pattern of mania as a discrete pattern without heat, stasis alone does not account for mania. Because static blood inhibits the engenderment of new blood, blood stasis may lead to vacuity heat just as heat may damage the blood lead to stasis. In any case, all chronic, enduring diseases tend to eventually become complicated with blood stasis. Therefore, in clinical practice, blood stasis typically combines with other disease mechanisms and manifests as simply one element of a more complicated pattern discrimination.

The contemporary Chinese medical treatment of withdrawal & mania

Although the disease categories of withdrawal and mania still appear in traditional Chinese medical textbooks on internal medicine, in real-life clinic, few patients are diagnosed as suffering from either of these two labels. Instead, Chinese patients are typically given other such diagnostic labels as depression instead of withdrawal, vexation and agitation instead of mania, or schizophrenia for either withdrawal or mania. The first of these more commonly used labels may be either a traditional Chinese or modern Western disease name. The second is solely a traditional Chinese disease category, while the third is strictly a modern Western diagnosis. In fact, the labels of withdrawal and/or mania are so rarely used in modern China that I and my co-author, James Lake, MD, state in Chinese Medical Psychiatry that we were unable to find any research on withdrawal and mania in the Chinese language Chinese medical journal literature.

Of course, having said that in print, I have recently come across a clinical audit on the Chinese medicinal treatment of withdrawal and mania. Written by Zheng Shu-ying and titled, "A Clinical Audit of the Chinese Medical Treatment of Withdrawal & Mania," it appeared in the July 2000 issue of He Nan Zhong Yi (Henan Chinese Medicine) on pages 48-49. This article describes the treatment of 125 cases of either withdrawal or mania with internally administered Chinese medicinals as water decoctions based on pattern discrimination plus small doses of Western psychotropic drugs. According to Zheng Shu-ying, the main signs and symptoms of withdrawal are emotional depression, taciturnity, feeblemindedness, muttering and talking to oneself, fear, a lack of calm, a bland or fiat affect, no thought for eating or drinking, spontaneous sorrow, slimy tongue fur, and a bowstring, slippery or fine, weak pulse. The signs and symptoms listed by Zheng for mania include rash, impetuous behavior, excessive talking, nonsensical sp eech, mania and agitation, lack of calm, injuring people and breaking things, cursing and yelling, headache, insomnia, and angry look in the eyes, a red face and eyes, a crimson red tongue with yellow, slimy fur, and a bowstring, slippery or fine, rapid pulse. Based on these signs and symptoms, Zheng says that withdrawal is mostly categorized as a vacuity condition, while mania is mostly categorized as a repletion pattern. A summary of Zheng's research appears below.

Cohort description

Of the 125 patients treated in this study, 60 were seen as in-patients and 65 were treated as out-patients. The oldest was 69 years old and the youngest was 14. There was no further breakdown of ages nor was any median age mentioned. Fifty-five patients were males and 70 patients were females. The shortest course of disease was one half month, while the longest duration of disease was 20 years. Unfortunately, the author also does not give any further breakdown of differences of duration nor a statement of median duration. What Zheng does say is that 81 cases were diagnosed as suffering from withdrawal and that the other 44 cases were categorized as suffering from mania. None of the patients in this study presented any obvious signs or symptoms of organic disease.

Treatment method

Patients diagnosed with withdrawal were further subdivided into three patterns. These were: 1) liver blood insufficiency, 2) liver qi depression and binding, and 3) heart-spleen dual vacuity. Patients diagnosed with mania were further subdivided into two patterns: 1) phlegm fire harassing above and 2) fire effulgence damaging yin. All 125 patients were primarily treated with Chinese medicinal decoctions combined with small doses of Western drugs. Those with withdrawal received sulpiride, and, in the afternoon, they received a small dose of chlorazine. Those with mania received intramuscular injections of holoperidol combined with orally administered chlordiazepoxide. Doses of these drugs were determined by the nature of the disease and the stability of the patient's condition. One and a half months equaled one course of treatment.

Withdrawal

1. Liver blood insufficiency pattern

Main symptoms: A sallow yellow facial complexion, vacuity vexation, insomnia, dizziness and vertigo, heart palpitations, night sweats, gallbladder timidity, easy fright, dry throat, heart mind abstraction, essence spirit fatigue and listlessness, no flavor for food or drink, spasms and contractions of the four limbs, trembling, or numbness, a pale tongue with scanty fur, and a bowstring, fine pulse

Treatment principles: Nourish the blood and quiet the spirit, clear heat and eliminate vexation

Medicinals: Semen Zizyphi Spinosae (Suan Zao Ren), 20g, Sclerotium Porine Cocos (Fu Ling), 15g, Radix Ligustici Wallichii (Chuan Xiong), 10g, Rhizoma Anemarrhenae Aspheloidis (Zhi Mu), 15g, Radix Glycyrrhizae (Gan Cao), 10g, Radix Albus Paconine Lactifiorae (Bai Shao), 15g, uncooked Radix Rehmanniae (Sheng Di), 15g, Radix Angelicae Sinensis (Dang Gui), 15g, processed Radix Polygoni Multiflori (He ShauWu), 20g. Oneji was administered per day decocted in water.

In actual fact, this pattern is not as simple as its name suggests. It includes an element of spleen vacuity as evidenced by the poor appetite as well as heart vacuity as evidence by the palpitations, neither of which are liver symptoms. I believe the reason this pattern is named as it is is that so many of the signs and symptoms are blood vacuity signs and symptoms. However, Dr. Zheng seems to realize that patients never present totally clear-cut, single organ patterns. Along the same line, in real-life clinical practice, at least here in the West, liver blood vacuity with an element of spleen qi vacuity is going to be complicated by liver depression. This is because the liver cannot manage its function of coursing and discharge if not nourished by sufficient blood. This helps explain the bowstring pulse which is not a standard pulse image of blood vacuity.

2. Liver qi depression & binding pattern

Main symptoms: Emotional depression, a bland or flat affect, speaking to oneself, nonsensical speech, chest and rib-side distention and pain, spirit mind abstraction, insomnia, slimy white or glossy, white tongue fur, and a bowstring, slippery pulse.

Treatment principles: Course the liver and resolve depression, transform phlegm, open the orifices, and quiet the spirit

Medicinals: Radix Bupleuri (Chai Hu), 12g, lime-processed Rhizoma Pinelliae Ternatae (Ban Xia), 12g, Pericarpium Citri Reticulatac (Chen Pi), 10g, Rhizoma Arisaematis (Nan Xing), 12g, Sclerotium Pararadicis Sclerotium Cocos (Fit Shen), 15g, Rhizoma Cyperi Rotundi (Kiang Fit), 12g, RhizomaAcori Graininci (Shi Chang Pu), 20g, Tuber Curcumac (Yu Jin), 20g. Radix Polygalae Tenuifoliac (Yuan Zhi), 15g, Fructus Immaturus Citri Aurantii (Zhi Shi), 10g, Lignum Aquilariae Agallochae (Chen Xiang), 10g. Oneji was administered per day decocted in water. If there was concomitant constipation, Radix Et Rhizoma Rhei (Da Huang) and Mirabilitum (Mang Xiao) were added. If there was insomnia and easy fright, Magnetitum (Ci Shi) and Cinnabar (Zhu Sha) were added.

As with pattern #1 above, this pattern's name also does not wholly describe all the disease mechanisms at work in it. The slimy or gloody tongue fur, the splippery pulse and the treatment principle, "transform phlegm," all indicate that the liver depression qi stagnation is mutually binding with phlegm.

3. Heart-spleen dual vacuity pattern

Main symptoms: Taciturnity, scanty speech, spirit mind abstraction, insomnia, malign dreams, impaired memory, heart palpitations, easy fright or sorrow and tears, bodily fatigue, scanty eating and/or loose stools, a pale tongue, and a fine, weak pulse

Treatment principles: Nourish the heart and quiet the spirit, fortify the spleen and supplement the blood

Medicinals: Radix Codonopsitis Pilosulae (Dang Shen), 15g, Rhizoma Atractylodis Macrocephalae (Bai Zhu), 15g, Radix Astragali Membranacei (Huang Qi), 30g, Radix Angelicae Sinensis (Dang Giti), 10g, mix-fried Radix Glycyrrhizae (Gan Cao), 15g, Radix Polygalac Tenuifoliae (Yuan Zhi), 15g, Sclerotium Poriae Cocos (Fit Ling), 15g, stirfried Semen Zizyphi Spinosae (Suan Zao Ren), 15g, Radix Salvise Miltiorrhizae (Dan Shen), 15g, Rhizoma Acori Graminci (Shi Chang Pu), 15g

Qneji was administered per day decocted in water. If there were heart palpitations, Cinnabar (Zhu Sha) and Succinum (Hu Po) were added. If insomnia was severe, Caulis Polygoni Multiflori (Ye Jiao Teng), Flos Albizziae Julibrissinis (He Huan Hua), and Dens Draconis (Long Chi) were added.

The formula above is a modification of Gui Pi Tang (Restore the Spleen Decoction), the standard guiding formula for a heart blood-spleen qi vacuity resulting in spirit disquietude. Interestingly, in some older, premodern Chinese medical texts, this formula is indicated for heart-spleen depression pattern. This other, premodern description of this formula's pattern indications is based on the insight that, in real-life practice, if the blood and spleen qi are both vacuous and insufficient, the liver must be depressed. The combination of several of the medicinals in this formula, such as Radix Polygalae Tenuifoliae, Radix Astragali Membranacci, and Sclerotium Poriae Cocos, insures the upbearing of the clear, downbearing of the turbid, and, therefore, the disinhibition of the qi mechanism and rectification of the qi.

Mania

1. Phlegm fire harassing above pattern

Main symptoms: Acute onset of disease, excitement and agitation, headache, insomnia, a red facial complexion, and angry look in both eyes, yelling and cursing at people, manic agitation and restlessness, strange, deranged speech, injuring people and breaking things, if severe, rushing on high and singing and laughing, a crimson red tongue with slimy, yellow fur, and a bowstring, slippery, rapid pulse

Treatment principles: Clear the liver and drain fire, settle the heart and wash away phlegm

Medicinals: Uncooked Frusta Fern (Sheng Tie Luo), 30g, uncooked Concha Haliotidis (Shi Jue Ming), 30g, bile-processed Rhizoma Arisaematis (Dan Nan Xing), 15g, Radix Gentianne Scabrae (Long Dan Cao), 15g, Rhizoma Coptidis Chinensis (Huang Lian), 10g, Radix Scutellariae Baicalensis (Huang Qin), 10g, Concretio Siliceae Bambusac (Tian Zhu Huang), 10g, Lapis Micae Seu Chloriti (Qing Shi), 30g, Rhizoma Acori Graminei (Shi Chang Pu), 15g, Cinnabar (Zhu Sha), 1.5g (swallowed down with the decocted liquid)

Oneji was administered per day decocted in water. If there was constipation with abdominal distention, Radix Et Rhizoma Rhei (Da Huang) and Mirabilitum (Mang Xiao) were added. If phlegm drool was congesting and exuberant, Succus Bambusac (Zhu Li) was added. If there was vexatious thirst and a dry throat, uncooked Gypsum Fibrosum (Shi Gao) and Rhizoma Anemarrhenae Aspheloidis (Zhi Mu) were added.

The fire of phlegm fire typically evolves from liver depression transforming heat. Therefore, there is a bowstring pulse and an angry look to the eyes as well as angry, aggressive behavior and speech. Traditionally, rushing on high and signing and laughing are usually part of the description of mania due to yang ming heat effulgence. However, I believe Dr. Zheng well recognizes the fact that depressive heat in the liver is often transmitted to the stomach, and then, from the liver and stomach counterflows upward to harass the heart spirit.

2. Fire effulgence damaging yin pattern

Main symptoms: Enduring manic disease with periods of remission characterized primarily by excessive talking, vexation and agitation, and a susceptibility to fright and periods of exacerbation manifest by agitation, mania, and restlessness, a red facial complexion and dry, chapped lips, an emaciated body, short, dark yellow urination, a red tongue with scanty fur, and a fine, rapid pulse

Treatment principles: Enrich yin and downbear fire, stabilize the mind and quiet the spirit

Medicinals: Herba Dendrobii (Shi Hu), 15g, uncooked Radix Rehmanniae (Sheng Di), 20g, Radix Scrophulariae Ningpoensis (Xuan Shen), 15g, Rhizoma Coptidis Chinensis (Huang Lian), 10g, Medulla Junci Effusi (Deng Xin Cao), 5g Herba Lophatheri Gracilis (Dan Zhu Ye), 6g, Cinnabar (Zhu Sha), 1.5g (swallowed with the decocted liquid), Sclerotium Pararadicis Poriae Cocos (Fa Shen), 20g, Plumula Nelumninis Nuciferae (Lian Zi Xin), 10g, Semen Zizyphi Spinosac (Suan Zao Ren), 30g

Oneji was administered per day decocted in water. If there was emotional abstraction with alternating periods of sorrow and joy, the ingredients of Gan Mai Da Zao Tang (Licorice, White & Red Dates Decoction) were added, i.e., mix-fried Radix Glycyrrhizae (Gan Cao), Semen Tritici Aestivi (Xiao Mai), and Fructus Zizyphi Jujubae (Da Zao).

Depressive heat and/or phlegm fire over time damage and consume yin fluids, thus resulting in yin vacuity. In that case, vacuous yin may be insufficient to control yang, in which case fire effulgence or vacuity heat may continue to counterflow up to harass the heart spirit above. The above formula contains ingredients to nourish and enrich yin fluids as well as to clear heat specifically from the heart, leading it back down to its lower source. Combining the main formula with Gan Mai Da Zao Tang suggests that this pattern is typically complicated by a heart-spleen qi vacuity. In real life, there is typically also liver depression.

Outcomes criteria

If all the clinical signs and symptoms disappeared, this was considered a clinical cure. If the symptoms markedly decreased, this was judged as marked effect. If the symptoms decreased from before to after treatment, this was defined as an effect, while if there was no change from before to after treatment, this was taken as no effect.

Based on the above criteria, 30 of the withdrawal patients were judged cured. Another 28 were judged to have gotten a marked effect, 18 patients, some effect, and five patients, no effect. Twenty of the mania patients were judged cured, 12 got a marked effect, seven got some effect, and five got no effect. Based on these numbers, the total effectiveness or amelioration rate was stated as 92%.

Conclusion

The treatment based on pattern discrimination for withdrawal and mania in Chinese Medical Psychiatry (Blue Poppy Press, Jan. 2001) is very similar to the above patterns and treatments described by Dr. Zheng. Although I prefer to use more specific and precise diagnostic categories for psychiatric disorders than simply withdrawal and mania, I think it is useful to know that Chinese medicinal treatment given for withdrawal and mania is statistically beneficial. More importantly, I also think it is useful to know that in the People's Republic of China, Chinese medicinal treatment for such psychiatric disorders is, at least in Dr. Zheng's hospital [2], given in combination with small doses of Western psychotropic drugs. Although Dr. Zheng does not give actual doses nor does he give a representative case history, I believe that the implications of the Chinese language used in this article are that, using Chinese medicinals, one is able to use a smaller dose of Western medicinals than normally prescribed when such drugs are used alone. Since many Western psychotropic and especially antipsychotic drugs have serious unwanted side effects, anything which helps to minimize the doses necessary of such drugs is a good idea.

References

(1.) In modern Chinese medicine as practiced in the People's Republic of China, psychiatry is a recognized clinical specialty referred to either as jing shen bing xue, psychiatry, or jing shen shen jing ke, psychiatry-neurology.

(2.) Dr. Zheng works at the Zhengzhou Municipal Psychiatric Prevention & Treatment Hospital in Zhengzhou, Henan

COPYRIGHT 2001 The Townsend Letter Group
COPYRIGHT 2001 Gale Group