The "Ask Dr. Jiang" column is designed to explore corners of Chinese medicine that may not be easily understood by American practitioners or are underrepresented in American clinical health literature.
Dear Dr. Jiang:
I haven't been able to find anything about manic depression / bipolar disorder in the modern Chinese reference books. Does Chinese medicine recognize this illness, and if so, what are its causes, and what are the guidelines for diagnosis and herbal treatment?
Qi Healer
Chicago, Illinois
Dear Qi Healer:
This is a big question, so I'm going to have to answer it in two installments. You're quite right; it's difficult to find any mention of bipolar disorder in the Chinese medical literature, particularly in the older classics. While there are abundant references to mania (kuang) and depression (dian) as separate entities, it is hard to find a clear description of a disorder involving mood swings between the two. While chapter 22 of the Ling Shu is titled "Dian Kuang," this chapter is really about mania, not depression; its description of dian being more suggestive of epilepsy than a mood disorder. We are left with the impression that the authors of the Nei Jing were much more concerned with mania than with depression, perhaps because of its more destructive manifestations. It is perhaps because of this that they never felt the need to describe a combined syndrome of manic depression.
The Chinese description of mania refers to a patient with abnormally outgoing, aggressive and excited behavior; who is easily angered, with a tendency to talk loudly or shout. The body movements are restless and forceful, and in extreme cases, the patient may strike things or even expose themselves in public. This is pretty close to the Western descriptions of the manic stage of bipolar disorder. In the case of depression, the behavior is the opposite: quiet, withdrawn, a low voice, and being untalkative, easily frightened or saddened. In extreme cases, patients may close themselves away from all social contact or mutter to themselves incoherently. In the simplest sense, we can say that mania belongs to yang and depression belongs to yin.
In spite of their obvious differences, mania and depression are both disorders of the spirit mind (shen zhi), and so it is possible in some cases for the two conditions to share the same etiology. Both mania and depression can be caused by excess emotions, for example. This is an important concept I explained in the January 2003 issue. Sometimes emotional disorders are caused by emotions themselves. Even if the root cause of an emotional disorder is physical in nature, extreme emotions can make the condition worse. Chapter 8 of the Ling Shu, for example, states that mania can be caused by extreme anger; by excessive joy, which damages the "inferior mind" (po); and by sadness, which damages the "soul" (hun). Another potential cause of both mania and depression is disorder of the heart and liver, the two body organs most responsible for generating emotions.
Some etiologies, however, are exclusive to one or the other. Yang heat excess, for example, can give rise to mania by disturbing the shen. Chapter 74 of the Su Wen states, "All mania belongs to fire." This fire is often caused by other pathogens stagnating in the body, such as blood stasis or phlegm, or by extreme emotions such as anger, joy, or even sorrow - the latter emotion causing stagnation which leads to fire.
In Clinical Guide to Case Studies, Ye Tian Shi wrote in the Qing dynasty that long-term worry can cause the qi to stagnate, which allows the phlegm to accumulate and "cloud" (hun xiao) the shen, causing depression. According to Ye Tian Shi, therefore, depression is essentially a disorder of yang qi. We can take this a step farther and say that there are two types of yang qi disorder that can lead to depression: excess and deficiency. Depression of yang qi, which we nowadays refer to as liver qi stagnation, is the more excess cause, and the one most often described in Chinese textbooks. Liver stagnation can cause stagnation by itself, or it can combine with phlegm. But depression can also be caused by yang qi deficiency, which leads to an overly yin constitution and an exhausted individual that wants to withdraw from social contact. Yang qi deficiency can cause depression in and of itself, or it can lead to phlegm accumulation causing the clouding effect described above. These various etiologies are compiled in the table below.
| CAUSES OF MANIA |
| Fire transformed from stagnation |
| CAUSES OF DEPRESSION |
| Yang qi deficiency (+ / - phlegm) |
| Yang qi stagnation ( + / - phlegm) |
| CAUSES OF BOTH MANIA AND DEPRESSION |
| Extreme emotions |
| Disorders of the liver and heart |
It's fairly easy to see how depression might transform into mania. According to Chinese medicine, anything that stagnates can turn into heat; the process is something like the warmth generated in the center of a compost pile. If the disease process causing the depression is yang qi stagnation, the stagnation will eventually transform into heat and this will produce mania - but transformation to excess fire is less likely to happen if the disease process causing the depression is yang qi deficiency. This helps to explain why not all patients with depression develop bipolar disorders; very deficient patients will lack the yang qi necessary to cause transformation to excess fire. If a patient's depression is caused by yang qi deficiency, therefore, additional pathologies are needed to cause mania. If there is phlegm accumulation or food stagnation, for example, transformation to fire may still occur, or the mania can develop directly from extreme emotions as described above.
It's a little bit harder to explain how mania might transform into depression. In fact, the process has never been formally described in the Chinese medical literature. Allow me, therefore, to offer my own opinion: the extreme yang of the manic state exhausts the body and damages the qi and blood, leading to the relatively yin state of depression. During the manic phase, the patient is extremely active, rarely sleeps, and often goes without eating. It's only a matter of time before the yang qi "runs out" and the patient's spirit is forced back into the more yin state of depression. If the yang qi should become stagnant again, the whole process starts all over again. The result is what modern medicine calls bipolar disorder.
I believe this explains the etiology of bipolar disorder. In the next installment, I will explain its differential diagnosis and treatment.
Edited with the assistance of John Pirog, MSOM.
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