Western Herbal Medicine – History, How Herbs Work, Safety and Efficacy

MEDICINALLY ACTIVE PLANT CHEMICALS

Plants do not have an immune system like ours to protect them from attack. Instead they use chemicals to fight bacteria, fungi and insects. Because these chemicals are biologically active, some also have medicinal properties.

Antimicrobials prevent the bulb rotting in wet soilGinsenosides

(triterpene saponins)

Protection against fungal diseasesThe tannins coagulate protein, so are an effective insect deterrentThe coagulating properties of bark tannins can be used for diarrhoeaEchinacea

Echinacea purpurea, pallida, augustiflora

Complex mix of alkylamides, caffeic acid derivatives, palyalkynes and polysaccharides

Antifungal compoundsare a defence against fungal diseaseStimulates the immune system. Used for upper respiratory tract infectionsSt John’s wort

Hypericum perforatum

Hypericin and pseudohypericin

 (naphthodianthrones)

Defence against insects that try to eat the plantBlocks neurotransmitter re-uptake. Used for depressionDeter or prevent insect or slug attackProvide its antispasmodic action. Used for indigestion

Since the 18th century scientists have been isolating the active constituents in plants. Research has given rise to some of the world’s most powerful drugs. Even today, modern medicine relies heavily on plant-derived drugs.

Not only have some of the more long-standing drugs such as digoxin, opiates and aspirin originated from plants, but many of the newer high-tech drugs such as the cancer drug vincristine and other cytotoxics (chemicals that kill cells) are also chemicals derived from plants.

Herbal medicines, however, are different from plant- derived drugs in that they consist of many chemical components. The mixture works in concert, making active constituents more easily available to the body, or buffering otherwise harmful ingredients. This means that the total therapeutic effect of the whole plant is considerably more than the sum of its chemical parts, since the active constituents’ effects will be modified by other substances. What’s more, the complex arrays of chemicals found in even the simplest plant medicines can trigger a cascade of biochemical processes in the living body. The way herbal medicines work is unlike the linear cause and effect of a single chemical (drug) acting on a single receptor system – a mechanism that pharmacologists are familiar with.

Understanding how plant medicines work calls for a leap into notions of “complexity” and “chaos” which are more familiar to physicists, than to biochemists or pharmacologists.

The consequences of using the whole plant rather than an isolated component are easily illustrated by clinical studies of garlic (Allium sativum). Recent research has shown that because garlic can lower blood pressure and cholesterol, it may be useful to people with coronary artery disease. Yet despite their best efforts, researchers have so far failed to identify which of garlic’s many chemical constituents are responsible for these medicinal virtues. Though formerly attributed to allicin, a compound found in garlic oil, it has recently become clear that the cholesterol- lowering effect of garlic results from a concerted action of several chemicals, not all of which are in the oil itself.

Research into St John’s wort (Hypericum perforatum) illustrates the same point. Trials have demonstrated that this ancient remedy is very effective in a wide range of depressive disorders, including seasonal affective disorder. It is as effective as modern antidepressant drugs in treating mild to moderate depression, but provokes virtually none of their side-effects. Researchers, however, cannot as yet assign the plant’s antidepressant effects to specific chemical components. Another group of chemicals with huge medicinal potential that is not yet well understood are flavonoids. These are chemical compounds that give many flowers, fruits and vegetables their colour. They display an amazingly broad range of medicinal activity: improving capillary fragility and circulation, protecting the liver and preventing heart attacks and strokes. Some are antioxidant or anti-inflammatory and antiviral, while others have demonstrable anticancer properties.

The rapidly expanding body of research into plant pharmacology is challenging the very basis of drug-based medicine. The realisation that many apparently minor chemical constituents, until recently overlooked, have significant medicinal properties has come as a revelation.

Herbal practice relies on the gentle and supportive nature of the remedies it uses. In contrast to conventional medicine, herbal practitioners focus on the person rather than the disease label. The herbal practitioner will explore the background of the illness taking a comprehensive case history, in which family and personal life are carefully evaluated. Questions cover lifestyle, exercise and diet, as well as how the patient feels about his or her circumstances (job, relationships, aspirations and anxieties). Then the practitioner is likely to perform a physical examination and may order clinical tests. All this information is used to assess the vitality of the patient, and establish which systems are sluggish and which are overworked. The practitioner will prescribe a mixture of herbs accordingly.

The herbal prescription is not a simple matter of using herbs in the place of drugs to treat a particular condition. Drugs are standardised, while herbal treatment rarely is. Each prescription is unique to the patient, matching the needs of that person, supporting ailing systems and/or reducing over-activity when it is apparent.

In practice, herbs are not usually used as “simples” (i.e. given singly), but are combined for extra effect to suit the individual. St John’s wort, for example, though marketed as a remedy to treat mild to moderate depression, is commonly combined with other herbs. When St John’s wort is combined with lemon balm (Melissa officinalis), it is used to treat anxiety and depression; with wild oat (Avena fatua) and/or ginseng (Panax ginseng), it is given for exhaustion; with valerian (Valeriana officinalis), it is a treatment for bipolar mood disorder.

Herbs often confer a wide spectrum of benefits. For example, lemon balm can be used for anxiety and insomnia, but it is also traditionally used for calming a nervous stomach and bowel. Recently it has been found to have a significant antiviral effect and may also help in the treatment of hyperthyroidism. Herbal remedies can support and stimulate the body’s healing response. The herbalist and the patient are partners in this aim, working together towards the common goal of restoring health.

It is clear that “natural” does not always equal “safe”, and that herbal medicines, like conventional medicines, can cause adverse effects. Such adverse events may also be due to contaminants present in herbs, such as heavy metals or aflatoxins, or even because of misidentification of a herb. There is a possibility of herb-drug interactions too (see below), Therefore herbal practitioners must be very well trained and know exactly what other medicines their patients are taking.

Safety concerns should be set in context. The European Herbal Practitioners’Association estimates that in 2003 there were over a million herbal consultations in the UK. According to a BBC poll (August 1999), herbal medicines are the most popular form of self-care.

It would appear that the incidence of herbal adverse effects is rather low. A five-year study into the occurrence of adverse events involving traditional herbal medicines and food supplements was undertaken by the UK National Poisons Unit. Of the 1,297 enquiries received, a medicine was implicated as a probable cause of the adverse events in only 38 cases. The Ministry of Agriculture, Fisheries and Food commented: “The findings overall are reassuring as they do not indicate any significant health problems associated with most types of traditional remedies and dietary supplements.” However, there have been a number of important concerns regarding the safety of herbal medicines in the past two decades. Using toxic Aristolochia species instead of safer herbs in some traditional Chinese medicines resulted in cases of serious kidney poisoning and cancer in Europe, China, Japan and the US.

Volatile oils such as menthol and thymol have a pungent aromatic aroma and a range of actions because they penetrate easily through the body’s tissues. Their molecules can even affect the brain directly through the nose. Herbalists have long known that the aroma of crushed mint (Mentha) or rosemary (Rosmarinus officinalis) can increase alertness and improve concentration. Internally, these oils are carminative, relaxing an over-contracted intestinal tract. They also stimulate the heart and lungs, improving circulation and deepening breathing. These oils are excreted through the lungs, kidneys and skin, so they act as expectorants and mild diuretics, causing therapeutic sweating. The traditional germicidal properties of many volatile oils, such as from thyme (Thymus), tea tree (Melaleuca alternifolia) and garlic (Allium sativum), are effective to a surprising degree. Garlic has recently been shown to combat the common cold and the hospital superbug MRSA.

Professor Ernst, Chair of Complementary Medicine at the University of Exeter, has recently downplayed the threat of adverse effects from herbal medicines. In an editorial in the British Medical Journal he comments that “Even though herbal medicines are not devoid of risk, they could still be safer than synthetic drugs. Between 1968 and 1997, the World Health Organization’s monitoring centre collected 8985 reports of adverse events associated with herbal medicines from 55 countries. Although this number may seem impressively high, it amounts to only a tiny fraction of adverse events associated with conventional drugs held in the same database. However, the relative paucity could also be due to a relatively higher level of underreporting

At present, the relative safety of herbal medicines is undefinable, but many of the existing data indicate that adverse events, particularly serious ones, occur less often than with prescription drugs.”

Only a tiny fraction of herbal medicines have been fully researched. In some cases, this has led to doctors doubting their efficacy. However, in the same editorial, Professor Ernst dispels the myth that herbal remedies are ineffective and lack credibility because they have not been researched. He writes, “The efficacy of herbal medicines has been tested in hundreds of clinical trials, and it is wrong to say that they are all of inferior methodological quality. But this volume of data is still small considering the multitude of herbal medicines – worldwide several thousand different plants are being used for medicinal purposes.”

Relatively few rigorous clinical trials have been conducted on herbal therapies mainly because, compared with the pharmaceutical sector, the herbal industry can rarely afford the considerable expense of a clinical trial.

Not being able to patent plant medicines and recoup the costs as drug companies are able to do, puts the herbal industry at a very real disadvantage. However, most of those clinical trials that have been conducted have shown that herbal medicines do work. In a recent overview of 23 systematic reviews (which are comparative and critical analyses of many research studies) of rigorous trials of herbal medicines, 11 came to a positive conclusion, nine yielded promising but not convincing results, and only three were actually negative.

In most developed countries, herbal medicines are subject to increasing regulation. Most major professional herbal associations are now reporting any side-effects so information may be shared among professionals. Proposed new European Union and UK medicines legislation will ensure medicinal plants are identified correctly. The European Directive on Traditional Herbal Medicinal Products, which became law in 2004, requires that over- the-counter herbal remedies should demonstrate at least 30 years of safe use to qualify for registration. Herbal remedies are now being officially listed for safety and efficacy by the European Medicines Evaluation Agency (EMEA). In 2003, the Herbal Medicine Regulatory Working Group set up by the British government published a report calling for the immediate statutory regulation of all UK herbal pract¬itioners. This means that British herbalists will be regulated and acknowledged by the state and other fellow health professionals, thereby ensuring that herbal medicines, which have been tried and tested over hundreds of years, will continue to play a part in everyday healthcare.

Herbal remedies, like all medicines, must be treated with respect. There are certain conditions and combinations of treatments in which herbs may cause problems.

General cautions

During the first three months of pregnancy, avoid all medicines, herbal or otherwise, unless absolutely essential.

• Certain herbs should be avoided throughout pregnancy, so consult a qualified medical herbalist.

• Women who are breast-feeding should consult a medical herbalist before using herbal medicines.

• Do not give babies under 6 months any internal herbal (or other) medicine without professional advice.

• The elderly, because of their slower metabolism, may require less than the full adult dose.

• Do not stop taking prescribed conventional medication without first consulting your doctor.

• Some herbs interact with drugs. If you are taking a prescribed medicine, consult a medical herbalist.

Herb-drug interactions

Herbs can change the way that your body absorbs and breaks down (metabolises) drugs. They can also affect other aspects of your metabolism, e.g. heart rate and blood pressure, which can mask or exacerbate symptoms. If herbs and drugs have similar actions, the combined effect can be too strong. This list of cautions is a guide to some of the potential drug interactions and situations when herbs should be used with care. Consult a medical herbalist about herb-drug interactions and contraindications.

Coltsfoot (Tussilago farfara) in excessive doses may interfere with blood pressure treatment. Also avoid long-term use.

Garlic (Allium sativum) in medicinal doses can cause a dangerous decrease in blood-sugar levels if taken with diabetes medication. Do not take it with the blood- thinning drug warfarin or other anti-clotting medication. (Culinary amounts of garlic are safe.)

Ginkgo (Ginkgo biloba) should not be taken with warfarin or other anti-clotting medication.

Ginseng, Siberian (Eleutherococcus senticosus) can increase blood pressure, so it should be avoided by anyone with this condition.

Goldenseal (Hydrasatis canadensis) can raise blood pressure. Consult a qualified herbalist if taking beta- blocker or other antihypertensive medications, or medication to control diabetes or kidney disease. Hawthorn (Crataegus spp.) may interact with other medicines, especially those prescribed for heart conditions. Hops (Humulus lupulus) have a mild sedative effect and act as a depressive. Do not take if you have depression, breast cancer, or other oestrogen-responsive cancers. Do not take with alcohol.

Lily of the valley (Convallaria majalis) contains cardiac glycosides and may interact with other heart drugs. It should only be taken when prescribed by a qualified medical herbalist.

Liquorice (Glycyrrhiza glabra) should not be taken by anyone who is anaemic, or has high blood pressure. Schisandra (Schisandra chinensis) should possibly be avoided by those with epilepsy or hypertension.

St John’s wort (Hypericum perforatum) increases the rate at which the liver breaks down drugs, so that a drug taken alongside it may not be effective. Drugs that may be affected include indinavir and other drugs used for HIV infection, as well as warfarin, cyclosporin, digoxin, theophylline and possibly oral contraceptives. St John’s wort may also cause sensitivity to sunlight, though this is most unusual within normal dosage range.

WHEN TO CONSULT A PRACTITIONER

The UK National Institute of Medical Herbalists and the National Herbalists’ Association of Australia keep registers of trained medical herbalists. Your doctor may also be able to make a recommendation. You should consult a medical herbalist before taking herbal medicines if you are pregnant or have a serious condition such as diabetes, heart disease or high blood pressure. Do not stop taking prescribed medication without first consulting your doctor. Some herbs and drugs interact – see above before taking a herbal medicine.

Integration of Scientific Research and Chinese Medicine to treat Depression

Although acupuncture has been practiced for over 3000 years (Ulett 1992), the Western psychological and psychiatric scientific community has produced little empirical research on the efficacy of acupuncture. With the notable exception of acupuncture as a treatment for substance abuse and dependence (for reviews see Brewington et al 1994, McLellan et al 1993), there are very few well-controlled empirical studies of the efficacy of acupuncture for psychiatric disorders. The need for empirical trials is underscored by recent surveys documenting the popularity of alternative treatments for psychiatric and emotional disorders (Cassidy 1998, Eisenberg et al 1993, 1998).

This category is written in the hope of articulating how the traditional principles on which acupuncture is based can be applied to the treatment of psychiatric problems. It is written for clinical practitioners of acupuncture, for researchers, and for other healthcare providers interested in learning about the potential use of acupuncture in the area of mental health. This category is designed to provide a standardized frame-work for the assessment of depressive symptoms from the perspective of Chinese Medicine (CM) and a manualized approach to devising treatment plans that are individually tailored to address each individual’s constellation of signs and symptoms. It may be helpful to clarify that throughout this text the term standardization is used when referring to the standardization of the methodology employed in assessment and treatment design — in this case primarily the eight guiding criteria — to emphasize the selection of a specific framework. It should be differentiated-ferentiated from the current trend towards standardizing the practice of Chinese Medicine to reflect exclusively the traditional (TCM) model (Fruehauf 1999). The approach presented in this categroy is not intended to serve as the sole and definitive approach to the clinical treatment of depression with acupuncture. The field of Chinese Medicine continues to grow precisely because of the rich diversity of clinical approaches that characterize the profession. It is hoped that this category can serve as a model and offer inspiration for other acupuncture traditions; the advancement of our profession will depend on making it amenable to scientific inquiry, which has become the ‘gold standard’ for evaluating treatments and making policy decisions.

It is intended that this manual will not only facilitate research, but also open the opportunity for acupuncture practitioners to implement a manualized treatment approach in their own practice. The benefits of using such a manualized approach are many, but include: (1) greater systematic attention to detail, (2) the opportunity to implement an experimentally tested protocol in routine clinical practice, and (3) the opportunity to gather data on the effectiveness of a researched approach in the real world setting of clinical practice.

The approach taken in this manual follows from standard principles of Chinese Medicine, which are described in detail in standard texts such as The Web That Has No Weaver: Understanding Chinese Medicine (Kaptchuk 1983), The Practice of Chinese Medicine (Maciocia 1994), The Foundations of Chinese Medicine (Maciocia 1989), and A Compendium of Traditional Chinese Medicine Patterns and Treatment (Flaws & Finney 1996). The manual is designed for use with persons that meet Western criteria for major depression of less than 2 years’ duration, according to the diagnostic criteria of the Diagnostic and Statistical Manual, fourth edition (DSM-IV; American Psychiatric Association 1994).

The features of the approach in this manual should be familiar to any practitioner trained in Chinese Medicine:

n An assumption that Western-defined depression is heterogeneous and may be characterized by one or more distinct patterns of disharmony, which may differ for different clients with depression.

Differential diagnosis using signs and symptoms, client interview, taking of pulses, and an examination of the tongue, integrating five areas:

—             eight principles

—             qi, blood and body fluids

—             viscera and bowels

—             channels and network vessels

—             five phases.

Given a pattern of disharmony or combination of patterns identified through differential diagnosis, the development of specific treatment principles.The selection of points to address the treatment principles.Acute treatments delivered twice per week for 8 weeks, and once per week for 4 weeks.Maintenance and continuation treatments semimonthly and then monthly for the next year.                       •A goal of producing clinically meaningful change: improved balance rather than disharmony, remission as defined by DSM-IV criteria, and Hamilton Rating Scale for Depression (HRSD) score 6.

Moreover, this manual details assessment and treatment suitable for persons with DSM-IV-defined major depression of less than 2 years’ duration. The details of diagnosing major depression are covered in the next post. It is not necessarily the case that the framework and techniques in this manual are not useful, at least in part, for people who do not meet the restricted criteria for major depression, but the effectiveness of this treatment for conditions other than narrowly defined major depression has not been investigated systematically. More ovei although the approach has been tested with women, it is currently being tested with men. In addition, the approach remains untested with clients with comorbid disorders, dysthymia, and chronic depression. Finally, although it is the authors’ view that acupuncture can be fruit-fully combined with psychotherapy, this manual covers the use of acupuncture as the exclusive treatment, without adjunct treatments such as psychotherapy, pharmacotherapy, or herbal interventions.

This category was written, with the aim of promoting sound scientific research on acupuncture and depression, while still providing flexibility and individualization in assessment and treatment planning — a necessary feature of Chinese Medicine. The theoretical paradigms that underlie acupuncture are very different from the Western medical models. Therefore, proper research studies in this field must incorpor-ate an energetic diagnosis based on the principles of Chinese Medicine (CM) in order to identify treatment protocols correctly, rather than rely solely on Western diagnostic systems (Bensoussan 1990).

The utilization of a manualized treatment approach in clinical trials involving acupuncture provides the essential flexibility necessary to deliver individualized treatment, while conforming to the standardization fundamental to conducting sound research. The use of a treatment manual promotes the systematic articulation of the chosen framework (in this case primarily the eight principles), thus providing replicability and systematization while allowing for individualized treatment. Additionally, a manualized treatment approach increases the quality and consistency of the treatment by standardizing the technical aspects, providing a precise framework for training and supervision, enabling the evaluation of practitioner competence and conformity, and increas-ing the ability to identify the most essential therapeutic aspects of the approach. A treatment manual should not aim at limiting treatment options within a narrowly defined protocol, but rather it should provide the freedom to identify a variety of treatment possibilities within a sound conceptual framework.

According to Chinese Medicine, any piece of information (symptom or sign) gathered from the client can be interpreted only in relation to other symptoms and signs. The integration and consideration of all significant variables that relate to the process of diagnosis and treatment is paramount in Chinese Medicine. Rather than eliminate variables in order to control the treatment outcome, Chinese Medicine seeks to integrate all significant variables, in order to create the most effective treatment. A certain flexibility is needed to assess accurately the efficacy of acupuncture, precisely because the theory of acupuncture is structured around the integration of data. Nevertheless, some standardization of treatment is necessary for the purposes of replication in research and clinical practice (Bensoussan 1990).

In other words, individuals who share a Western diagnosis (e.g. depression) will be characterized by a variety of CM-based patterns of disharmony which, in turn, dictate particular treatments to address these patterns of disharmony. Treatments, therefore, must be tailored to each individual’s symptom picture; a ‘standard’ treatment must not be uniformly administered to all individuals who share a Western diagnosis. This manual describes the framework and procedures by which acupuncturists may reliably arrive at individualized diagnoses and treatment plans. In pilot work designed specifically to assess how well individuals could agree using this framework and these proce-dures, five women with major depression were seen independently by two acupuncturists within a 3-day period. Overall agreement was quite high, as indicated by an intraclass correlation coefficient1 of 0.78, summarizing their composite agreement. This result suggests that practitioners can agree on which pattern(s) of disharmony char-acterize any given individual’s depression, and agree on the treatment that should ensue.

Aside from our pilot study (Allen et al 1998), which is detailed in a future post, the only studies of acupuncture as a treatment for depression or depression-like syndromes have been published in China (Chengying 1992, Han 1986) and in Eastern Europe and the former Soviet Union (Cherkezova & Toteva 1991, Frydrychowski et al 1984, Polyakov & Dudaeva 1990, Polyakov 1987, 1988). It is difficult to evaluate these studies fully, because the diagnostic criteria used differ from those of the DSM-IV, and because most of these studies have not been translated into English (other than the abstracts). Collectively, however, these studies suggest that acupuncture may be effective in the treatment of depression and depressive symptoms, in some cases as effective as tricyclic antidepressant medication. The following review summarizes these studies, with a focus on the range of depressive symptoms for which acupuncture may and may not be effective.

Polyakov (1988) treated 167 depressed patients with acupuncture. Acupuncture reduced the principal symptoms of depression and also lessened the severity and prominence of supplementary symptoms. The best results from acupuncture were obtained in patients with melancholic depression; poor results were obtained in patients with anxious and apathetic depressions. Acupuncture was almost as effective as antidepressants in cyclothymic depressions and was notably inferior to tricyclic antidepressants in patients with psychotic features. Moreover, Polyakov (1988) reported that follow-up studies over 1-2 years indicated that adequate maintenance therapy produces results comparable to drug therapy, although inadequate information was provided to evaluate this claim. In this study, acupuncture was carried out using a standardized method of treatment that consisted of five acupuncture points located in the traditional meridians (St 36, P S, P 6, Lu 7, and LI 4) plus three ear acupuncture points (AT affect, AT Shenmen, and AT Zero). From the perspective of pattern differential diagnosis (the assessment method of Chinese Medicine), the finding of poor treatment response in anxious and apathetic depressions is not surprising, because this set of points does not specifically address the features present during anxious or apathetic depressions. This highlights the importance of considering individual differences in symptom presentation and tailoring points accordingly, as detailed in this manual.

Other studies provide only abstracts in English. Chengying (1992) used points on the Du channel (which runs along the spine) to treat a melange of psychiatric disorders including anxiety, depression, hypochondria, neurasthenia, obsessive—compulsive disorder, aphasia, alexia, and hysterical paralysis. A total of 115 patients with a course of disease from 2 months to 8 years were treated with points selected from the Du channel. Points were selected by pressing the points one by one, observing and comparing sensitivity to the points, and choosing to needle the 1-2 points with the maximum response. Of the 115 patients, 61 experienced complete disappearance of psychoneurotic and somatic symptoms and no recurrence at 6-month follow-up, 31 experienced a significant improvement, and 23 had no significant improvement after treatment. Although Chenying (1992) studied a heterogeneous group, the comparability of the diagnoses neurasthenia and major depression was noted by Chang (1984). Commenting on the observations of Dunner & Dunner (1983), Chang indicated that almost 50% of psychiatric outpatients in China are diagnosed with neurasthenia, and that many of these neurasthenics would be diagnosed by the DSM with major depression. Moreover, Chang (1984) noted that antidepressants were as effective with cases of neurasthenia diagnosed by Chinese psychiatrists as with cases of DSM-defined depression.

A further 103 patients with neurasthenia (course of disease from 3 months to 20 years, average of 4.5 years) were observed clinically at the Academy of Traditional Chinese Medicine (Suobin 1991). Principal points Du 14, Du 13, GB 20, the first line on the Bladder channel, bilateral to the spine and the Huatuo paravertebral points (M BW 35 (Jiaji); O’Connor & Bensky 1981) were used, along with other points chosen according to symptoms. Following treatment 45 patients were relieved of all their symptoms and were considered clinically cured, 29 experienced an improvement of the main symptoms but some secondary symptoms remained, 21 experienced a noticeable improvement, and eight had no improvement at all.

Another Chinese study, by Luo, Jia, and Zhan of the Institute of Mental Health, Beijing Medical College, examined electro acupuncture and amitriptyline treatment of DSM-III-defined major depression. This study, summarized by Han (1986), found comparable decreases in HRSD scores as a function of electro acupuncture and amitriptyline treatments over a 5-week interval: mean ± SD HRSD scores dropped from 28.5 ± 1.2 to 12.8 ± 2.0 for patients receiving acupuncture, and from 29.4 ± 1.4 to 14.2 ± 1.9 for those receiving amitriptyline. Moreover, fewer side effects were reported for patients receiving electroacupuncture. Unfortunately, this study used only two points (Du 20 and Yintang), and it is unclear whether standard needling, as opposed to electroacupuncture, would provide compara-ble results, although some (Ulett 1992) claim that the effect of acupuncture is due entirely to the frequency of stimulation rather than to the specific points selected. Another Chinese study (Hechun 1988; summarized by Brewington et al 1994) also found comparable decreases in depressive symptoms in patients having electroacupunc-ture and those receiving amitriptyline. Finally, acupuncture also appears to diminish depressive symptoms in the context of opiate detoxification (Cherkezova & Toteva 1991, Newmeyer et al 1984).

Although far from definitive, taken together these studies suggest that it is possible to obtain favorable results using acupuncture to treat mood-related symptoms, including depression. These findings encouraged us to undertake a pilot study to examine the efficacy of acupuncture as a treatment for depression.

Chinese Medicine Theory – The Assessment of Depression Within the Framework of Chinese Medicine

Although any acupuncturist using this manual would be knowledgeable of the basic concepts of Chinese Medicine (CM), and would probably be familiar with the eight guiding criteria as a style of treatment, a complete section on the theoretical framework is included. This has been done for the sake of continuity as well as to introduce the nonacupuncture community to the Chinese Medicine conceptualization of depression. The aim is not only to provide a clinical tool for acupuncture practitioners but also to foster understanding and collaboration between acupuncturists, psychotherapists, physicians, and researchers.

Theoretical References

In the development of our treatment protocol for depression, we sought to integrate five areas or ‘filters’ (Seem 1985) which serve as the basis for assessment and treatment in acupuncture:

1. Yin/yang and eight guiding criteria

2. Viscera and bowels

Qi, blood and body fluidsChannels and network vesselsFive phases.

The pilot study outlined in a future post, as well the framework for this manual, are based primarily on the first three filters: (1) the eight guiding criteria, (2) viscera and bowels, and (3) qi, blood, and body fluids. These three filters are generally used together as a unit. Although the different theories that serve as the foundation for the five areas can be artificially compartmentalized, in reality they function together as a whole, and are all necessary to understand the etiology and progression of imbalances. The approach presented in this manual aims to integrate what we have found to be the most useful features of each ‘filter’ in the evaluation and treatment of depression, while emphasizing the use of the eight guiding criteria, viscera and bowels, and qi, blood and body fluids, as the foundation for treatment design. All five areas mentioned above are used in some way to explain the disease mechanisms that underlie depression, to understand the pattern differentiation characteristic of depressive episodes, and to outline the treatment principles and treatment strategies for point selection. We use the step-by-step methodology characteristic of eight principles pattern identification: (1) differentiate signs and symptoms using the four evaluations, (2) establish disease mechanisms, patterns, and pattern combinations, (3) outline treatment principles, and (4) design a treatment plan. We have, however, deviated from what is commonly known as traditional Chinese Medicine (TCM) in essentially three ways: first, we make extensive use of the five-phase theory in the initial interview to determine the specific nature of each person’s experience of depression; second, we encourage palpation of the abdominal area, and the channels for point selection; and third, we modify our point selection and total strategy over time, on the basis of channel interactions that are not emphasized in TCM. Such channel interactions are more broadly used by the Vietnamese and French acupuncture schools, some Japanese acupuncture styles, and the acupuncture style developed by Dr Mark Seem.

After having used this manual extensively, as both a clinical and a teaching tool, it became obvious that the treatment strategies that had been used consistently as part of our treatment protocol expanded the framework beyond the TCM model. The rationale for point selection, point combinations, and point location, although based on TCM (‘TCM is a style of Chinese Medicine that emerged predominantly from the People’s Republic of China in the twentieth century, and which is presented as the standard model of Chinese Medicine in mainland China today. For an interesting discussion of TCM, its history, development, and clinical standards, see Fruehauf (1999).) pattern differentiation, was heavily influenced by training under Mark Seem. Seem’s approach developed through the influence of the French energetic school of acupuncture, and the work of Dr Van Ghi. For this reason, the section that describes the channels and network vessels deviates from standard TCM theory to include a broader consideration of the complexity of the channel system, which has very little importance in TCM as a style of treatment today. Although purists in any of these traditions may argue against combining different styles of treatment, in reality the contemporary practice of acupuncture has emerged as a ‘weaving of lineages within the diverse traditions that make up Oriental medicine’ (Hougham 2000). In line with this view, the authors hope to make a small contribution towards the development of a foundation for a multidimensional energetic approach to the assessment and treatment of depression — one that allows the practitioner to stratify treatment options based on an integrated use of the five filters. It needs to be emphasized, however, that any system that may emerge from this endeavor — to be authentic and internally coherent — must develop on a solid foundation: one that is based on a clearly articulated theoretical framework and a consistent treatment methodology.

The authors recognize the validity and significance of diverse schools of thought in the treatment of depression with acupuncture. We selected the eight guiding criteria as the primary framework for our study because in our view: (1) the eight criteria offer a methodological approach that can be more easily replicated in control studies, (2) most of the existing research literature for acupuncture in the treatment of depression uses the eight guiding criteria directly or indirectly, (3) the reference literature available in English is based on these criteria, and (4) the eight guiding criteria as a style of treatment offers more consistent treatment protocols. It is of great interest to the authors to be able to compare — in the future — different styles of treatment and their clinical outcomes, but this was not an aim of our pilot study, nor of this category.

In order to establish a parallel between Western-defined major depression and acupuncture patterns of disharmony, we looked at depression as a complex interplay of disease mechanisms that develop from three main factors: (1) the patient’s predisposing tendency towards vacuity or repletion of either yin or yang, (2) the liver’s inability to maintain the free and smooth flow of qi, and (3) a disturbance in the heart’s function of housing the spirit (shen).

In this way, the question we pose within the context of Chinese Medicine is not only whether someone is depressed, but how this person is experiencing depression, and what precipitating factors — physical, psychological, and social — have contributed to his or her present condition. Chinese Medicine offers, then, a framework for understanding distinct symptom pictures and for developing a treatment approach based on the nature of each individual’s particular symptom pattern. Thus acupuncture treatments focus on the entire symptom picture, which includes physiological as well as psychiatric symptoms.

Chinese philosophy is based on the premise that all life occurs within a unified system, that all phenomena are manifestations of a unifying principle of energy or life force, and that all manifestations of life are connected and mutually dependent upon one another. Life unfolds as a process of differentiation that expresses the interaction between two complementary forces, yin and yang, which represent the totality of the dynamic equilibrium. This unified system is understood as a process of fluctuations and permanent change, as the cyclic nature of continuous movement. Everything can be characterized as either yin or yang, relative aspects of an alternating cycle along a single continuum (Beinfield & Korngold 1991). The creative principle that symbolizes life in all its forms and which activates every process that characterizes living entities is known as qi (pronounced `chee’) or `vital energy’, and is central to Chinese medical theory.

Human beings are considered a microcosm that reflects the universe that surrounds them — a dynamic series of energetic fluctuations constitutes the body as a living system (Seem 1987). Each of us is an ecosystem living within a larger ecosystem. The balance of forces within us determines our health and disease (Beinfield & Korngold 1991).

Acupuncture looks for disharmonies of qi and, strictly speaking, depression does not exist as a disease category in Chinese Medicine. When an acupuncturist using the eight-principles framework is asked to evaluate a ‘depressed’ person, he or she weaves all relevant information into a pattern of disharmony, a description of the dynamics that portray a situation of an imbalance. Symptoms are part of this imbalance which can be seen in other aspects of the patient’s life and behavior (Kaptchuck 1983). Because the patient is always considered as a body—mind continuum, somatic and psychological symptoms are equally important.

By focusing on the detection of qi imbalances, rather than on the diagnosis and treatment of disease, Chinese Medicine explains relation-ships between physiological and psychological events that are considered separate phenomena in the Western medical model. Chinese Medicine offers a physiology that postulates a clear connection between somatic events and psychological concepts of mind and emotion, helping to close the gap between soma and psyche (Seem 1987). As with any other diagnostic system, the theoretical framework provided by Chinese Medicine can be used to understand the appearance of symptoms that characterize depression, to account for the heterogeneity of symptom presentation in depression, and to devise individually-tailored treatments for particular constellations of depressive symptoms.

Chinese Medicine defines health as the balance between yin and yang, which depends on the capacity of an organism to adapt to change and maintain equilibrium. Sickness is the result of vacuity or repletion of either yin or yang. Vacuity is defined as: weakness of the forces (right qi) that maintain the health of the body and fight disease, an insufficiency of vital substances (yin, blood, body fluids, essence; i.e. yin humor), or the diminished capacity of physiological processes. Repletion is defined as: an accumulation of physiological products (phlegm, dampness, blood, and qi) that are harmful to the body and may obstruct functioning, or as the relative excess of either endogenous or exogenous pathogens (in Chinese Medicine endogenous or exogenous pathogens are known as ‘evil qi’ (xie). They include the six qi (wind, cold, fire, summerheat, dampness, and dryness) in their capacity to cause disease; the ‘warm evils’ (warm heat school), and various types of toxins. Additional pathogens are wind, cold, fire, dampness and dryness arising within the body, and static blood and phlegm produced by the body (Wiseman & Feng 1998).) that may threaten the health of the organism. Vacuity and repletion are both imbalances between yin and yang.

The homeostasis of an organism — the balance between yin and yang — is sustained by the proper circulation of qi along energetic pathways or meridians, commonly known as the channels and network vessels. The channels form a network that connects the surface of the body with the internal organs (viscera and bowels), serving as a two-way communication system, which both conveys messages to the surface about internal malfunctioning and alerts the internal functions about surface phenomena that might be threatening to move deeper into the system (Seem 1987). The channels and network vessels are the surface manifestations of the viscera and bowels, and act as an irrigation system that regulates the supply of qi and prevents accumulations. The internal organs in Chinese Medicine are defined by their functions and interrelations, rather than by their somatic structures or specific anatomic locations. They work as spheres of influence, and represent a complete set of functions that reflect energetic relationships among physiological and psychological events. In order not to confuse them with the biomedical entities of the same name, we refer to them as viscera (yin) and bowels (yang); they are also sometimes referred to as organic—energetic functional units, organ functions (Seem 1987), organ networks (Beinfield & Korngold 1991), or energetic orbs (Porkert 1983). There are five viscera and six bowels. The viscera and bowels and the channels both work in pairs, with one yin and one yang function interconnected:3 lung—large intestine, stomach—spleen, heart—small intestine, kidney—bladder, pericardium—triple heater, liver—gall bladder, yin and yang respectively.

The Chinese characters for yin and yang denote the sunny and shady sides of a mountain respectively. These two complementary and opposing principles are used to describe phenomena that have a similar quality and relationship, including the different functions and parts of the body. Yin and yang are rooted in each other: they are interdependent, relative to one another, divisible but inseparable. Yin and Yang counterbalance and complement each other and transform into each other.

The pericardium is considered as an extension of the functions of the heart and it is said to act as a buffer that protects the heart from external influences; it is not considered a separate viscera. In the context of the channels and network vessels, the pericardium is a channel in its own right and is considered the yin pair of the triple heater channel. Therefore, there are five (yin) viscera and six (yang) bowels; but there are six yin and six yang channels or meridians.

The potential for differentiation into yin and yang (earlier heaven), upon which life depends, is received from our parents at conception and stored in the kidney. The kidney has a very special relationship with the other viscera and bowels because it holds the foundation for their own yin and yang (Kaptchuk 1983). Each of the other viscera and bowels is considered to have a yin (storing, nour-ishing, cooling) component and a yang (activating, protective, warming) component, which are said to stem from the yin and yang roots of the kidney, respectively (Seem 1987). According to Kaptchuck (1983), yin is what sustains and conserves the organism and grants us the qualities of rest, tranquility, and quiescence; yin condenses and concentrates inwardly the energy of life. Yin moistens, softens, stabilizes, and roots life, and grants us the capacity to unfold gracefully while being content, quiet, and present. When yin is insufficient, we lack the qualities of receptivity and contemplation and become easily agitated, unsettled or nervously uneasy; the control over the dynamic manifestations of heat and activity is lost (Kaptchuk 1987). Yin represents the latent potential that awaits to be expressed and organized (Seem 1987).

Yang, by contrast, causes transformation and change, providing us with the capacity to engage life, to react, and to respond. Yang expands and disperses outwardly, granting the basic animating and invigorating quality of life that expresses our capacity to move, activ-ate, and transform. When yang is insufficient, we find ourselves para-lyzed in fear, confused and indecisive, unable to &press what we want, hopeless. When the quickening power to move is lost, the expression of life becomes soggy, congested, inactive, and frozen (Kaptchuk 1987).

Usually, we can detect in every person a relative vacuity of either the yin or yang roots of the kidney, which will affect in turn the rela-tive vacuity or repletion (hypoactivity or hyperactivity) of the associ-ated yin or yang viscera and bowels (Seem 1987). These tendencies, which can be both trait and circumstantial, will influence the manner in which an individual responds to his or her environment and the stressors therein.

When considering the human being as a smaller system living within a larger system, individuals’ relationships to their environ-ment become of the utmost importance in the development of illness. Each of us will experience an event and react to a stressor in a dif-ferent way. Our predisposition to develop a disorder at any given time depends on our individual experience of being in the world. Situations that create a conflict between our internal needs and desires and the demands placed upon us precipitate personal patterns of reaction based on our relative vacuity or repletion of either yin or yang (Seem 1987).

Based on this model, major depression can be considered as a `somatic energetic reaction pattern’ that is fueled by psychological and physical energies that are unique to the individual and that affect the experience of the disorder and nature of the symptoms. Moreover, this somatic energetic reaction pattern will influence the treatment protocol and prognosis. Stated differently, although persons with major depres-sion may share common symptoms, for each individual the dynamics of dysfunction would have developed in such a way that will require indi-vidualized treatment based on differential energetic diagnosis.

Fundamental Substances: Qi, Blood, Essence, Spirit, and Body Fluids

Qi

things; all physical and mental activities are manifestations of qi, and qi is perceived functionally by what it does (Beinfield & Korngold 1991). Sometimes referred to as ‘vital energy’ or simply ‘energy’, the concept of qi is much broader: qi is what motivates all movement, transformation, and change. According to Chinese Medicine, qi has five functions: defense, transformation, warming, restraint, and trans-portation. Qi protects the exterior of the body from invasion by exter-nal pathogens; it transforms substances so that they can be used by the organism; it provides warmth for the entire body; it holds the organs and substances in their proper place; and it propels all movement and transportation in the body.

Blood

According to Chinese Medicine blood is the substance that nourishes and moistens our body tissues. Blood is derived from food by the stomach and spleen, it is governed by the heart, stored in the liver, and moved through the vessels by the combined action of the heart and lung. When the blood is scanty or insufficient, no functions can take place; the blood moistens all body tissues, including the ligaments and tendons known as sinews in Chinese Medicine, as well as the skin and the eyes. Without proper nourishment and moisture, the tissues of the body can stiffen, dry out, and wither.

Blood and qi are very closely interrelated. In the human body, qi is the yang in relation to blood, which is the yin. The qi moves the blood, and the blood provides the material foundation for the qi. Blood, being yin in nature, provides nourishment and moistening, as well as the material foundation for the shen or spirit, which is yang. By accumulating in the heart, the blood helps to house and anchor the shen, and keep it rooted in the body (Schnyer & Flaws 1998). Later on, we will look in detail at some of the mental and emotional symptoms experienced during depres-sive episodes, which result from insufficiency or stagnation of blood.

Spirit

The Chinese concept of shen, or spirit, corresponds to the mental capac-ity to think, feel, and respond; it is what allows us to be conscious and alert during the day, and what becomes inactive during sleep. In that sense, shen refers to the Western concept of ‘mind’ (Wiseman & Feng 1998). In Chinese Medicine shen represents the accumulation of qi and blood in the heart; sufficient qi and blood accumulating in the heart are necessary to give rise to consciousness or spirit (Schnyer & Flaws 1998). Because shen is considered to have a material basis, its importance in medicine is not independent of the body. Kaptchuk (1983) refers to shen as the capacity of the mind to form ideas and the desire of the person-ality to live life. Human consciousness, memory, mental and emotional faculties, and awareness all indicate the presence of shen. For there to be consciousness and awareness, there needs to be sufficient qi; for the spirit to be quiet and calm, there needs to be enough blood to nourish it and settle it. Without sufficient blood (yin), the shen or spirit (yang) becomes restless; without enough qi our mental clarity is impeded (Schnyer & Flaws 1998).

Essence

Essence is the most fundamental, essential material the body utilizes for its growth, maturation, and reproduction (Schnyer & Flaws 1998). Essence determines the strength of the constitution. In women, the outward manifestation of essence is blood; in men it is semen. There are two forms of this essence: inherited essence, which is the constitutional basis acquired from our parents, and acquired essence, derived from the food and liquids we consume and the air we breathe. The natural process of living is the way in which we utilize this essence; we come to the world with a limited supply of inherited essence, our lifestyle choices determine the rate with which we use up this supply. Because all body functions depend on this essence, and because inherited essence cannot be replaced, it is very important to conserve it.

According to Chinese Medicine our inherited essence is a reservoir, and it is the acquired essence we create by eating, drinking, and breathing that provides the foundation for the qi and blood we utilize for our daily activities. If we eat properly, and through digestion we transform food and drink efficiently into nourishment (qi and blood), we produce sufficient qi and blood to perform our day-to-day activi-ties. If, in addition, we have a good night’s sleep, any surplus of qi and blood that was not utilized during the day goes on to bolster our inherited essence and become part of our reservoir (Schnyer & Flaws 1998). Inherited essence is governed and stored by the kidney; acquired essence is governed by the spleen.

This is, in part, the reason why digestion and diet are instrumental in understanding the mechanisms that underlie chronic and recurrent depression, why depression is more prevalent in women than in men (Kessler et al 1994), and why aging may be a risk factor in depression (Beekman et al 1999).

Body Fluids

The concept of body fluids comprises all the normal fluid substances of the human body; this term refers to fluids actually flowing within the human body, and to sweat, saliva, stomach juices, urine, and other fluids secreted or discharged by the body (Wiseman & Feng 1998). The body fluids are therefore different to the previous four concepts, as these fluids are the same as would be described in Western medicine. Body fluids in Chinese Medicine are differentiated as liquid fluids, which are thinner, mobile, and relatively yang in quality, and humor, which are thicker, less mobile, more turbid, yin fluids. The main function of the fluids is to keep the viscera and bowels, the skin, the hair, and the body orifices moistened; addition-ally, they lubricate the joints and nourish the brain, marrow and bones (Wiseman & Feng 1998).

The formation, distribution, and discharge of fluids involve complex processes in which several viscera and bowels play important roles. The processing of fluids begins in the stomach, where the useful part of the fluids (essential qi) is absorbed. The spleen carries this essential qi to the lungs, from where it is distributed to the other parts of the body. The small intestine separates the clear from the turbid, whereas the large intestine further absorbs fluid while conveying the waste material downward. Finally, the kidney plays the most impor-tant role in the formation and replacement of fluids by providing the warming and activating force for the other viscera and bowels to perform their roles; in addition, the kidney is responsible for trans-forming the surplus and waste fluid into urine, to be later discharged by the bladder.

The relationship between the concepts of viscera and bowels in Chinese Medicine and the organs as we know them in Western medicine is mostly of name and not of function. As mentioned above, the organs of Chinese Medicine represent a complete set of functions, both psychological and physiological, and are defined by their inter-action rather than by their anatomic structure. Each viscus and bowel has a responsibility for maintaining the physical and mental health of the organism. The viscera (relatively yin organs) store the essence and are responsible for creating and transforming qi and blood; the bowels (relatively yang organs) decompose food and convey waste. As mentioned above, there are five viscera — liver, heart, spleen, lung, and kidney (the pericardium is considered a sixth viscus in channel theory) — and six bowels: gall bladder, small intestine, stomach, large intestine, urinary bladder, and triple heater. The viscera and bowels are paired by functional relationship, respectively.

`The Liver holds the office of General of the armed forces. Assessment of circumstances and conception of plans stem from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallée 1985, p. 34)

The liver controls ‘coursing and discharge’, meaning that it regulates the smooth and unobstructed flow of qi and blood. The liver maintains the uninhibited and free movement of qi throughout the body in order to prevent stagnation.

According to Hammer (1990), the liver is the first line of emotional defense for the entire organism; when confronted by a noxious emotional stimulus, this energy system is the organism’s first choice for coping with the stressor. The liver deals with the stressors by assuring constant movement and circulation of qi, thus preventing stagnation.

The liver network expresses the capacity for growth, development, expression and change. Any experience that would inhibit this potential would directly affect the ability of the liver to maintain free flow. Any intense emotion that would find no release through verbal expression or physical activity would increase the demand on the nervous system for qi and blood, and would potentially render the liver incapable of renewing and circulating noxious energy (Hammer 1990). A condition of blockage or stagnation of qi would set in. Emotions, and especially anger and frustration, are the primary causes of liver qi stagnation.

Liver qi stagnation affects, in turn, other functions of the liver such as storing the blood and regulating digestion. It may also manifest as a blockage along the pathway of the liver channel (which traverses the pelvis, abdomen, chest, throat, gingiva, and head). Depending on the viability of the organ systems in a particular individual, liver depression qi stagnation may affect the functions of other viscera and bowels. The combination of liver depression with predisposing factors precipitates, in turn, the cascade of disease mechanisms that characterizes each distinct pattern of disharmony present during depression. We will explain further the concept of qi stagnation, its relationship to depression, its complications and ramifications.

Because the first effect of the emotions as causative factors of disease is to upset the liver’s function of coursing and discharge (i.e. the movement and transformation of qi and its proper circulation and direction), liver depression qi stagnation is likely to always be a significant factor in mental—emotional problems.

The term ‘liver depression qi stagnation’ is a technical one used in Chinese Medicine to denote a particular disease mechanism and pattern of disharmony that involves the liver and that implies qi stagnation due to emotional stress and frustration (Wiseman & Feng 1998).

`The Heart holds the office of Lord and Sovereign. The radiance of the spirits stems from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 23)

The heart is considered to be the emperor of the bodymind, the gov-ernor of the five viscera and the six bowels. The heart stores the shen or spirit, and is therefore considered to be the seat of consciousness and mental functions. If the heart is working normally, and qi and blood are abundant, the mind is lucid, alert, and responsive to the environment (Wiseman & Feng 1998 ).

Mental illnesses and emotional disorders in general affect the heart, but rather than originating in the heart itself, damage by the emotions begins in some other viscus or bowel eventually affecting the heart (Schnyer & Flaws 1998). All emotions affect the heart besides affecting their corresponding viscus or bowel (Maciocia 1994). Many of the symptoms characteristic of mental and emotional imbalance, such as sleep disturbances, incoherent speech, confusion and disorientation, anxiety and palpitations, correspond to an inability of the heart to perform the function of housing the shen. The heart’s ability to house the spirit can be affected by disease mechanisms that precipitate either vacuity or repletion patterns. When we refer throughout this manual to the concept of shen disturbance, we are referring to the different patterns that affect the heart’s function of housing the shen or spirit.

`The Spleen and Stomach are responsible for the storehouses and granaries. The five Wei (tastes) stem from them.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 64)

The spleen assimilates nutrients from food in the stomach to make qi, blood, and fluids; it governs the movement and transformation of food and water and the distribution of its essence (nutrients), playing a very important role in the creation of qi and blood. In Chinese Medicine it is said that the spleen is the source of qi and blood formation (Wiseman & Feng 1998), the source of engenderment and transformation (Schnyer & Flaws 1998). On the one hand, if the spleen becomes diseased it may not be able to create and transform sufficient qi and blood to nurture the heart and to provide mental clarity and awareness. On the other hand, if it fails in its function of moving and transforming body fluids, dampness may accumulate and lead to phlegm. Phlegm in Chinese Medicine denotes a viscous (yin) fluid that, when accumulated, may cause disease anywhere in the body; it may create a disturbance of the heart spirit and affect mental functions characterized by confused thinking, dullness of thought, brooding, and rumination.

`The Lung holds the office of Minister and Chancellor. The regulation of the life-giving network stems from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 30)

The lung is responsible for breathing and the production of qi; it moves and circulates the qi out to the edges of the body and from the top downwards. It assists the metabolism of body fluids by carrying water downwards to the bladder and preventing the accumulation of water in the body. In addition, the lung helps to protect the body from invasion by external pathogens. Like the heart, the lung is often affected by disease processes initiated in other viscera and bowels. For example, when liver qi stagnation affects the lung, it may create a sense of constriction in the chest, breathlessness, and a tendency to weep.

`The Kidneys are responsible for the creation of power. Skill and ability stem from them.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallee 1985, p. 76)

As we saw previously, the kidney as a single functional unit provides the basis for our congenital constitution; it stores the essence and holds the foundation for the yin and yang of all other viscera and bowels. The essential qi of the kidney is responsible not only for our reproductive capacity but also for the growth, development, and aging of the body (Wiseman & Feng 1998). In addition, any enduring disease damages the kidney, including mental and emotional problems. The harmonious relationship between the kidney and the heart is fundamental for the physical and mental wellbeing of the organism; these two viscera are interdependent and counterbalance each other. The kidney is the seat of the essence (jing), while the heart is the abode of the spirit (shen). Jing and shen, essence and spirit, soma and psyche, are aspects of a continuous process. Shen refers to the organizing force of the self, whereas jing refers to the material substance; together they refer to the totality of the human being (Beinfield & Korngold 1991).

`The Gall Bladder is responsible for what is just and exact. Determination and decision stem from it.’ (Su Wen, Ch. 8; cited in Larre & Rochat de la Vallée 1985, p. 43)

The main functions of the gall bladder are to secrete bile, which is formed from an excess of liver qi, and to govern decision. This last function implies that the capacity to maintain a balanced judgement in the face of adversity is attributed to this bowel; strong gall bladder qi ensures less vulnerability to external stimuli (Wiseman & Feng 1998), greater courage, and less timidity.

The gall bladder, however, plays a very important and somewhat peculiar role in the clinical treatment of mental—emotional disorders. This role is based on the relationship that the gall bladder has to the heart on the one hand, and to the liver on the other. The 11 organs are said to depend on the gall bladder and, therefore, if the qi of the gall bladder is strong, endogenous or exogenous pathogens cannot enter. These two statements link the gall bladder to the heart and its spirit, and elevate it to a place of greater importance (Schnyer Flaws 1998). The relationship between the heart and the gall bladder is further emphasized by a Chinese Medicine theory known as the `midday—midnight law’. This theory states that the circulation of qi along the channels is said to take its course over a period of 24 hours; according to this theory there is a special clinical relationship between viscera and bowels, which receive their maximal flow at opposite times of the day (Mann 1973). The heart has its maximal activity at 12 noon, while the gall bladder has its maximum activity at 12 mid-night.’ If the gall bladder is stimulated through acupuncture, the heart will be stimulated as well. It is interesting to note in this regard that several acupuncture points located on the gall bladder channel have a very profound effect on the treatment of mental—emotional conditions. Furthermore, the gall bladder is considered ‘the official residence of clear fluids’ (Flaws 1994) and it influences the transformation of body fluids. Therefore, points along the gall bladder channel are very effective in the treatment of patterns that involve accumulation of dampness and phlegm obstructing mental clarity, which are frequently found in depression. It is also worth mentioning that the guiding herbal prescription traditionally used to treat these type of patterns (phlegm dampness, obstruction, and stagnation, phlegm confounding the orifices of the heart, heart vacuity—gall bladder timidity, and phlegm fire harassing the heart) is known as `warm the gall bladder decoction’ (wen dan tang).

Also, the gall bladder stands as the yang counterpart of the liver. When qi (which is yang) accumulates, it becomes hot and tends to move in a yang direction: upwards. Therefore, stagnant liver qi com-monly moves into its paired yang channel, the gall bladder; symptoms of liver depression qi stagnation commonly appear along the course of the gall bladder channel as fullness, distension and lack of free flow (Schnyer & Flaws 1998 ).

Stomach

The stomach is the first to receive foods and liquids into the body; it is in the stomach that foods and liquids are first collected and are broken down to allow their nutrients to be absorbed. In complementary opposition to the spleen, which extracts the nutrients from food and sends them up to the lungs to be distributed, the stomach sends the food down to the intestines to be further absorbed and eliminated. In Chinese Medicine it is said that the spleen upbears the clear and the stomach downbears the turbid to explain this complementary relationship. Together with the spleen, the stomach has a pivotal role in the creation of qi and blood; many of the disease mechanisms respon-sible for depression due to insufficiency of qi and blood are a result of disturbance in the functions of both the stomach and the spleen. In repletion patterns it is very common to find stagnant liver qi attacking the stomach and upsetting its downbearing function, and for liver heat to collect in the stomach. Liver depression qi stagnation can render both the stomach and the spleen incapable of performing their respective functions. On the one hand the stomach becomes ‘dry and hot’ and cannot downbear the,turbid, while the spleen becomes ‘damp and weak’ and cannot upbear the clear. In addition, because the heart is said to be located above the stomach in Chinese Medicine and, because heat tends to rise, stomach heat counterflows upwards and agitates the heart (Schnyer & Flaws 1998).

Functions of the Viscera and Bowels and their Role in Depression

Depression, as well as any other mood disorder, can be a manifes-tation of an imbalance in certain functions of the viscera and bowels. Emotions are considered to be manifestations of qi that, if not expressed or transformed, become stagnant; they become a cause of disease only when they are experienced excessively or for a prolonged period of time, or both (Maciocia 1994). When the qi does not circulate properly, it becomes noxious and generates an imbalance.

Chinese Medicine does not separate physiological and psychological events; the shen or spirit is made by both qi and blood, which in turn are generated by the viscera and bowels. At the same time, the functions of the viscera and bowels, our qi, and our spirit are affected by external circumstances. In Schnyer & Flaws (1998), Bob Flaws explains it in this way: ‘the mind arises as a function of the viscera and bowels, but the functioning of the viscera and bowels is affected by the experiences of the mind and the emotions’ (p. 15). He goes on to say: ‘every thought or felt emotion is nothing other than the experience of the movement of qi … [C]hanging the way the qi moves, one changes one’s mental—emotional experience, while changing one’s mind and emotions changes the way the qi moves’ (p. 15).

The lung, spleen, and kidney (particularly the yang aspect of the kidney) are the viscera more directly involved in the production and transformation of our qi; the quality and quantity of qi depends on their functions. Therefore these viscera are most likely involved in patterns of depression due to vacuity of qi/yang or accumulation of dampness and phlegm. Owing to the role the liver plays in maintaining the free movement of qi (and blood), it will likely be involved in patterns resulting from qi stagnation, although the stag-nation may also directly affect the heart and lungs. The surplus of qi generated by liver depression qi stagnation can, over time, when severe or when combined with predisposing factors, create a predominance of yang (heat or fire). Yang repletion may accumulate in the liver, the heart or the stomach, and it may also consume yin, primarily of the liver, the kidney, and the heart. Liver depression qi stagnation may also progress into blood stasis, or it may generate accumulation of dampness or phlegm. Shen disturbance can be a result of either vacuity or repletion disease mechanisms that stem from dysfunction in other viscera and bowels; shen disturbance implies an imbalance in the heart’s function of housing the shen or spirit.

The most important viscera associated with the mechanism of depression are the liver, heart, and spleen; however, the kidney and lung also play important roles. The gall bladder and the stomach are the only two bowels that have special significance in depression. In brief, we will look at the role of each of these viscera and bowels in the precipitation of depressive episodes.

Acupuncture is said to adjust the density and flow of qi in the chan-nels and network vessels, which in turn affects the circulation of other vital substances (blood and body fluids) and the function of the viscera and bowels. Chinese medical theory, as it relates to acupuncture, encompasses five areas that provide the framework for assessment and treatment (Seem 1987). These areas are:

Eight guiding criteriaQi, blood, and body fluidsThe viscera and bowelsThe channels and network vesselsThe five phases.

Based on the training and style of the practitioner, one of these areas may be used primarily or several may be used in combination. We have explained in some detail some of the basic theoretical con-cepts that serve as the foundation for the aforementioned assessment areas. We now describe how the information gathered by examination is then organized using each one of these assessment areas as ‘filters’, through which we interpret the information.

The Eight Principles

The eight principles or eight guiding criteria are four sets of bipolar categories that help to differentiate and interpret the information gathered during examination (Beinfield & Korngold 1991). They serve as a conceptual matrix that enables the practitioner to organize the relationship between particular clinical signs and yin and yang (Kaptchuk 1983). Disease patterns can be identified by means of these eight fundamental principles: interior—exterior, cold—heat, vacuity—repletion and yin—yang. They determine the relative location, nature, and quality of the imbalance and constitute the basis of dif-ferential diagnosis from which the patterns of disharmony evolve. Interior and exterior describe depth of the disease; cold and heat describe the nature of the disease; vacuity and repletion describe the relative strength or weakness of one’s own right qi in relationship to pathogenic qi; yin and yang are the general categories that embrace the other six principles (Wiseman & Feng 1998). Interior, cold, and vacuity are yin features, whereas exterior, heat, and repletion are yang features. Each principle is associated with specific signs; by matching the patient’s signs the depth and nature of the diseases can be determined, as well as the relative strength of the.forces that resist the disease and those that cause it (Wiseman & Feng 1998).

Seem (1987) developed a phenomenological model that explains the mechanism for the development of vacuity and repletion patterns of either yin or yang, depending on one’s constitutional tendencies of `becoming hot’ (yang) or ‘becoming cold’ (yin). According to Seem’s model, we can interpret disease patterns as ‘somatic energetic reaction patterns’ that develop along one of two continua: yin deficiency—yang excess (hyperactivity and increased metabolic response) or yang deficiency—yin excess (hypoactivity, decreased metabolic response). In this view, when confronted with an emotional stressor or a perceived threat, the organism would tend to react in one of two ways: by activating sympathetic response in preparation for `fight or flight’ (yang) or by withdrawing from external activity and parasympathetically attending to internal demands and allowing the organism to ‘rest and digest’ (yin). If sympathetic activation is pro-longed, the organism exists in a chronic state of readiness, with the corresponding physiological reactions. Yang overtakes yin. If, on the other hand, the response is parasympathetic, the body will withdraw from action into a dependent stage, retreating from danger and looking for help. Yin overtakes yang (Seem 1987).6

We can use this interpretation of eight principles pattern differentiation to establish a parallel between these two reaction tendencies and the various symptoms of major depression. Each of the DSM-IV symptoms of major depression has corresponding symptoms of vacuity and repletion (deficiency/excess) of either yin or yang.

Qi, Blood, and Body Fluids

The mechanisms for the generation, transformation, and movement of qi, blood, and body fluids, which we explained above, are used as the conceptual matrix to understand the interactions and manifestations of yin and yang in the human body. Yin and yang are water and fire in the world, whereas qi and blood are fire and water in the body (Schnyer & Flaws 1998). As seen earlier, body fluids are also either yin or yang, depending on their function and nature. Essence and spirit also form a complementary yin and yang pair.

‘As we can see in Figure 3.1, if the yin of the kidney becomes situated on the left side of the five phases diagram, and the yang of the kidney on the right, when the yin of the kidney is vacuous or deficient ‘becoming hoe tendencies develop along the phases (and associated viscera) that are on the left; and ‘becoming cold’ tendencies due to yang vacuity develop along the phases (and viscera) on the right.

Clinically, when using qi, blood, and body fluids as a diagnostic filter, one determines the relative insufficiency or accumulation of qi and blood, the quality of generation, movement, and transformation of body fluids, and the condition and presence of the essence and spirit. In addition, the clinician evaluates the functional interactions between the viscera and bowels responsible with the production and movement of these ‘substances’. The use of qi, blood, and body fluids as a theoretical framework, in conjunction with the eight principles and the viscera and bowels, together constitute the foundation for TCM as a style of treatment.

Channels and Network Vessels

The network of channels in the human body is composed by four major systems: (1) the 12 regular channels, (2) the eight extraordinary vessels, (3) the secondary vessels, which include the tendinomuscular, connecting, and linking channels, and (4) the divergent channels. There are, in total, 71 channels (Seem 1990).

There are various approaches to using the channels and network vessels as a filter. For example, one may focus on knowing which level — defensive, nourishing, ancestral — is affected, in order to treat the corresponding network (Seem 1990). Alternatively, one may emphasize the treatment of the areas irrigated by the channels, as zones that are said to be structured and organized by the particular influence of each channel (Seem 1993). One may also use the concept of the six great units as constitutional diathesis (predisposition to disease) based on Yves Requena’s (1986) approach. The framework used throughout this manual incorporates these last two concepts: (1) the influence of the channels on different areas of the body when making our final point selection and (2) the six great units as consti-tutional diathesis, for understanding predisposition to the different pattern combinations.

The Channel System

The 12 Regular Channels

The 12 regular channels form the basic structure of the channel system and provide a network of qi and blood by which the whole body is nourished (Wiseman & Feng 1998). There are six yin and six yang channels, three of each on each hand and three of each on each foot. Each channel homes to viscera and bowels that stand in an interior—exterior (yin—yang) relationship. In addition to being paired by their internal—external relationship (yin—yang), the regular channels are also paired by the same polarity (yin or yang), with one arm channel and one leg channel to form the six great units; this results in a complex set of interactions that allow the acupuncturist to make subtle interventions to restore balance. Figure 3.2 lists the names of the 12 regular channels, their abbreviations, and their relationships.

The Eight Extraordinary Vessels

The eight extraordinary vessels are thought to develop prenatally before the development of the main channels; their function is to supplement insufficiencies of the other channels. The extraordinary channels do not home to any organs and do not have an interior—exterior relationship; they connect channels of the same polarity, whether yin or yang (Wiseman & Feng 1998). The extraordinary channels are du mai, ren mai, chong mai, dai mai, yang wei mai, yin wei mai, yang chao mai, and yin chao mai.

The Secondary Vessels

The secondary vessels include the tendinomuscular channels, the con-necting and the linking channels. The tendinomuscular channels run parallel to the regular channels on the surface of the body. The linking channels (luo) include 12 channels for each regular channel, plus one for du mai and one for ren mai. They extend the influence of the main channels to other parts of the body (Low 1983).

Two relationships between the channels are shown: in the right-hand column, the internal—external or yin—yang relationship is highlighted: one viscus and one bowel of the same phase are paired. On the left-hand side, the relationship that corresponds to the six units, between the upper and lower branches of each channel, is emphasized.This relationship underlines the correspondence between the viscus or bowel of one phase, with the viscus or bowel of a different phase.Adapted with kind permission from Seem ( 1987).

The Divergent Channels

The divergent channels leave the main channels at various points, but do not rejoin them; instead they join their coupled yang channel (Low 1983). They are considered of equal importance to the regular channels.

The channels are said to develop from conception through adult-hood; each channel level is said to carry a different kind of qi: defensive (wei), nourishing (ying), and ancestral (jing) (Seem 1990). The first to develop are three of the extraordinary vessels (du mai, ren mai, and chong mai; see below); then comes dai mai, followed by the remaining four extraordinary vessels. The second set of channels to develop are the tendinomuscular, followed by the regular, and finally the connecting, linking, and divergent pathways. For a summary of the different channel levels and their functions.

Channels and Network Vessels in the Treatment of Depression

In our protocol, we use primarily the regular channels because we are aiming at addressing dysfunction of the viscera and bowels. It is pos-sible, however, to develop a framework based on addressing the different channel levels mentioned above; it can be argued, for example, that depression is a stress response that should be treated initially at the level of the character armor (tendinomuscular level), or that one should aim at treating the core through the use of the extraordinary channels (Seem 1990). Clinically, it may be extremely useful to combine, in a progressive fashion, the use of the different levels. We hope to explore this possibility in the future. The present approach, however, involves solely outlining the rationale for the inclusion of some point combinations aimed at balancing two extraordinary channels, du mai and chong mai.

Du Mai

As summarized in this post, some studies conducted in China used points along du mai to treat symptoms associated with depression. Du mai, or the governing channel, plays a very important role in depres-sion. Du mai is one of the eight extraordinary channels and does not have a corresponding viscera or bowel. It emerges from the kidney; it is the storehouse of the yang, the sea of the yang channels, and has a regulating effect on the yang qi of the whole body. It begins its pathway at the perineum and ascends along the spine, up over the head and into the mouth. It is said in Chinese Medicine that the gov-erning vessel homes to the brain and nets the kidney. Since the kidney engenders the marrow and the brain is known as the ‘sea of marrow’, the governing vessel reflects the physiology and pathology of the brain and the spinal fluid, as well as their relationship to the reproductive organs (Wiseman & Feng 1998). The points along its pathway have been used traditionally, among other things, to affect mental func-tions. An excess of qi along the channel would mean an exuberance of yang: too much energy traveling ‘upward’ towards the head or stuck in the upper part of the body creating irritability, restlessness, and insomnia. An insufficiency in the flow of qi along its pathway will result in the inability of total yang of the organism to circulate, raise, and nourish the brain and spinal cord, manifesting as apathy, flat affect, and inability to express enthusiasm or emotion. The section on point indications provides greater detail on how we have used du mai in our protocol.

Chong Mai

Chong mai is where all the qi and blood of the 12 regular channels converge and it is considered to have a regulating effect on all of them (Wiseman & Feng 1998). The transportation and movement of the qi and blood of the whole body is focused on the chong, and therefore it is called the ‘sea of blood’ (Flaws 1997). The chong mai arises from the kidney and connects the liver with the pericardium (jueyin), bringing together the functions of menstruation (liver) and reproduction (kidney) with the heart’s function of housing the spirit. Chong mai is traditionally indicated in the treatment of menstrual and gynecological disorders, and it is broadly used to treat morning sickness during pregnancy.

In its pathway, the chong mai raises up through the regions irrigated by the liver and kidney (yin), connecting the peritoneum, the pleura, and the pericardium, and serving as the foundation upon which all the functions of the viscera and bowels develop (Seem 1990). The chong mai comprises the entire visceral cavity, and integrates the areas primarily affected by stagnation of liver qi.

The liver rules the area of the diaphragm and the region of the ribs. When confronted with a stressor, one commonly tightens up the diaphragm as well as the musculature of the chest and the upper back, the throat, the jaw, and the head. If this constriction of the diaphragm develops into a chronic stress response, the upper and lower regions of the body become ‘split’, as if one was cut off, so to speak, at the diaphragm, leaving the lower parts of the body vacuous and weak (kidney yang vacuity) and creating hyperactivity and agitation in the upper parts of the body (shen disturbance). In people experiencing depression, it is very common to find a constriction in the diaphragm, and neck and shoulder tension (liver qi stagnation), in combination with symptoms of decreased metabolic response on the one hand (kidney yang vacuity) and anxiety and agitation (yin vacuity—hyper-activity of yang) on the other. Chong mai allows us to integrate the complex relationship of patterns found in depression that involve the liver, the heart, the spleen, and the kidney simultaneously.

The Five Phases

The relationship between yin and yang is further differentiated into identifiable stages that describe the process of change between situations and across time. These stages — wood, fire, earth, metal, and water — are known as the five phases and reflect the transformation of yin into yang, and vice versa. Like yin and yang, the five phases are categories of quality and relationship (Wiseman & Feng 1998). Change is a process that takes place gradually as qi moves around the cycle represented by the five phases. According to the five phases theory, phenomena in the universe are the result of the movement and mutation of these five entities. Wood, fire, earth, metal, and water rep-resent certain qualities and relate to one another in specific ways; any other group of five phenomena that have qualities and relate to each other in similar ways are said to correspond to the five phases (Wiseman & Feng 1998;).

Yin, which expresses the potential of the bodymind (i.e. totality of soma and psyche), is characterized by water, and corresponds to the apparent quiescent stasis of the winter — a time when, beneath the surface, germination is preparing to bring forth the renewal of spring. It represents the capacity to store, generate, charge, and restore after release (Beinfield & Korngold 1991). Water is the moistening and descending to low places’ (p. 206); it corresponds to the blackness of the night, and with saltiness, the taste of sea water (Wiseman & Feng 1998).

Fire characterizes yang, the dynamic principle, the sense of splendor and fulfillment experienced when light, warmth, and interaction are at their peak. Fire symbolizes the end point of expansion and con-summation, of completion and fulfillment (Beinfield & Korngold 1991). ‘Fire is the flaming upward, and has the quality and upward movement’ (p. 205); it is associated with summer, with the color red, and the bitter taste (Wiseman & Feng 1998).

The transition of yin (the seed and the root) into yang (the flower and fruit) is represented by wood, an ascending movement of sudden growth and rapid expansion, of unexpected but unpredictable change (Beinfield & Korngold 1991). Wood is the bending and the straightening’ (p. 205), it grows upward and stretches outward; it corresponds to the spring, the time of growth and the beginning of the cycle of the seasons, it is associated with the green of new leaves in the sour taste of unripe fruit (Wiseman & Feng 1998). When the life force reaches its greatest expression, it begins to slow down, collapsing inward.

Metal represents the capacity for separation and refinement that is expressed in the autumn, when the energy contracts in order to consolidate, when the leaves fall and fertilize the soil for the next spring (Beinfield & Korngold 1991). ‘Metal is the working of change’ (p. 206), having the qualities of purification, elimination, and reform; it is associated with the white color of frost, and with the purifying action of acrid smelling things (Wiseman & Feng 1998).

These processes happen as we find ourselves on the earth, the point of reference that locates us in time and space. Earth represents our capacity for changing direction without losing balance, and is the axis around which other aspects orient themselves (Beinfield & Korngold 1991). ‘Earth is the sowing and reaping’ (p. 206), representing the planting and harvesting of crops and the bringing forth of phenomena. Earth is associated with yellow (the Chinese word includes brown), and with the sweetness of ripened fruit (Wiseman & Feng 1998).

Clinically, the five phases constitute a system for understanding the movement of qi through the five viscera; each of the five viscera corresponds to each of the five phases. Wiseman & Feng (1998) illustrate the relationship between the functions of the five viscera and the qualities of the five phases as follows:

`The liver controls the movement of qi around the body; it spreads qi just as the trees spread their branches; and as trees and other plants sprout upwards in the spring, so the liver yang tends to stir upwards. The heart has the function of propelling qi and blood to warm and nourish the whole body; it is like a fire that drives the body, just like the heat of summer makes nature flourish. The spleen is the source of qi and blood, that nourish and drive the body, just like the earth brings forth the crops at the end of the summer. The lung helps transform the fluids into blood, it controls the downward movement of the fluids to the kidney and bladder, and in this way is responsible for the purifying removal of waste fluids; it has the purifying qualities of the autumn frost. The kidney stores essence, just as nature preserves itself in winter dormancy.’ (Wiseman & Feng 1998, p. 206)

The five phases explain the etiology and nature of qi imbalances, providing in this way the framework for an energetic physiology to further comprehend the disturbances of the bodymind (Seem 1987). In addition to having similar qualities to one another, the phenomena associated with the five phases relate to other phenomena associated with the same phase in a similar fashion; for example, water engenders wood, and winter gives way to spring, and so the kidney (water) nourishes the liver (wood). Each phase corresponds to a set of channels and to a viscus and a bowel paired by their yin—yang relationship. (Each paired system is commonly identified by the name of the yin function: liver—wood, heart—fire, spleen—earth, metal—lung, water—kidney.)

According to Beinfield & Korngold (1991), every viscus and bowel has a responsibility or job to do, a strategy on how to do the job, and a character or way to do it, which reflects the nature of the energy represented by its pertaining phase. Every phase characteristically influences physiological and psychological functions that in turn correspond to the particular viscus (and bowel) associated with it. There is a corresponding tissue, sense, body fluid, sound, and smell associated with each phase. In addition there is an emotion and a mental aspect associated with each of the five phases. A more comprehensive description of the correspondence between the five phases, the five viscera, the emotions, and the mental aspects associated with each one of them is given in ‘The seven affects and the five emotions’ and ‘The five spirits’ sections below.

Correspondences of the five phases

In the context of the five phases, depression can be considered an imbalance in the movement of qi along the cycle of transformation of the energy. The five phases interact with one another according to pat-terns of generation and restraint which explain their capacity and provide the motivating impulse for their potential (Beinfield Korngold 1991). Illness is considered a process, not a static entity. When using the five phases as the basis for diagnosis and treatment, the system of correspondences is used to identify constitutional tendencies and to determine the configuration presented by the interaction of signs and symptoms, in order to attend to the root of the patient’s imbalance. Emotional disturbances are well explained using the theory of the five phases as a framework, which makes it an especially useful tool to understand distinct constitutional predispositions to depres-sion, to reframe the symptoms experienced by the person, and to develop a model for patient education.

As seen above, each of the five phases and its corresponding viscus has an associated emotion. These five emotions — anger, joy, worry, sadness, and fear — are considered to be manifestations of qi, basic forms of emotional activity; they become a cause of disease only when experienced excessively, for a prolonged period of time, or both (Maciocia 1994). Two emotions, anxiety or oppression, and fright, are added to these five to complement the gamete of human emotions; together they constitute the seven affects. Oppression reinforces other emotions such as sadness, obsessive thinking, or fear; it represents contraction, lack of circulation, immobilization (Larre & Rochat de la Vallée 1996); sometimes translated as anxiety (Wiseman & Feng 1998), this emotion is attributed to the lung or spleen, depending on the context (Larre & Rochat de la Vallee 1996). Commonly, fright refers to being startled with fright, and can mean any movement of the body, such as shaking or convulsions; it corresponds to the liver.

When disease originates from emotional causes it is known in Chinese Medicine as internal damage, affect damage, or damage by the emotions. (In Chinese Medicine, disease is said to originate from one of three causes: internal, external, or neutral (neither internal nor external). The emotions are said to be the internal causes of disease and are not to be confused with evils that arise internally such as internal fire or internal wind, which may develop from affect damage, but which can also be the result of insufficiency or transformation of external evils (Wiseman & Feng 1998).)

When the emotions are experienced persistently or intensely, they can alter the balance between yin and yang, blood and qi, and adversely affect the functions of the viscera and bowels. For example, whereas the liver, heart, and spleen seem to be involved most directly with the core symptoms of major depression, the interactions of these with other viscera and bowels can play a role in the appearance of other physical and psychological symptoms that may be seen during depression. These are symptoms for which depressed individuals may visit a physician, only to find no medical basis for their complaints. Because all symptoms, both physiological and psychological, are rele-vant in Chinese Medicine, these additional symptoms are equally important in determining the pattern of disharmony underlying depression. These symptoms help to establish the diagnosis and selec-tion of treatment principles and points.

For example, anger causes the qi to rise and can create distension and fullness in the rib cage and breasts, headaches, dizziness, and red, sore eyes; because the liver stores the blood, ascendant liver qi may carry the blood with it and cause nose bleeding. Because the liver and the spleen are closely related through the control cycle of the five phases, excessive liver qi moves across, ‘attacks’ and affects the spleen, making it incapable of performing its functions of transportation and transformation. A very common scenario encountered in depressive episodes is liver qi stagnation (frustration, irritability) in conjunction with a weak spleen, or spleen vacuity (weight changes, worry, abdominal distension); this weakness of spleen may, in turn, generate dampness or phlegm accumulation (yin repletion). Anger can also affect the stomach (nausea/vomiting), large intestine (irritable bowel), lungs (coughing and wheezing), and heart (agitation, insomnia).

Joy causes the qi to slacken; excessive joy leads to a dissipation of shen, or spirit, and a weakening of the heart qi, manifesting as heart palpitations, insomnia, and some mental diseases (Wiseman & Feng 1998) such as mania. Worry and overthinking cause the qi to bind, affecting movement and transportation and causing shallow breathing, fullness in the chest (lungs) and stomach, poor appetite, abdominal distension, and loose stools. They can also cause neck and shoulder stiffness (gall bladder, liver) (Maciocia 1994).

Sadness (grief) corresponds to the lungs. It causes the qi to disperse and can deplete lung qi, which manifests with a weak voice, breath-lessness, and weeping, or a feeling of constriction in the chest. According to Maciocia (1994), sadness may also affect the liver and create mental confusion, a lack of sense of direction, and an inability to plan; when held in for many years, it can affect the kidney and its regulation of fluid metabolism.

Incontinence or diarrhea may be caused by fear, which makes the qi descend and corresponds to the kidney. Fright, which in the summary above is associated with the heart, causes chaos and derangement of the qi, manifesting as disquietude of the spirit, and possibly more severe mental illness (Wiseman & Feng 1998).

Affect damage or damage by the emotions can originate from and/or give rise to vacuity or repletion patterns. Shen disturbance vacuity patterns manifest primarily as heart blood or heart yin vacuity, and to a lesser extent as heart qi vacuity; they generally stem from constitutional or circumstantial predisposition to qi and blood vacuity. Shen disturbance repletion patterns stem from either liver depression or spleen and kidney vacuity. -When originating from liver depression, they manifest as qi stagnation affecting the heart, depres-sive heart agitating the spirit, or blood stasis blocking the heart’s orifices; when stemming from spleen and kidney vacuity, they manifest as variety of patterns that derive from phlegm obstructing the orifices of the heart.

The Five Spirits: Five Mental Aspects of the Bodymind

In addition to the spirit (shen), which is stored by the heart, each yin viscus houses a specific mental aspect of the human mind. The shen itself indicates consciousness and memory; it maintains our awareness and expresses the integration of our being. The liver stores the hun, usually translated as the ethereal soul. The hun is said to complement the functions of the shen, and it is related to intuition and inspiration, insight and courage. The hun gives us a sense of direction and the capacity for planning; it influences sleep and dreaming. In the spleen is stored the yi or reflection, which represents our verbally expressed thoughts, our capacity for applied thinking, studying, memorizing, focusing, concentrating, and generating ideas. The kidney stores the zhi, which corresponds to will, drive, and determination; it also pro-vides us with the capacity to store information and is related to long-term memory. The po or corporeal soul is stored in the lung and is what gives the body its capacity for movement, physical sensation, and coordination. It can be linked to the physical expression of the hun or to the organizational principle of the body, and it is considered to be closely related to the essence, considered the foundation of human life.

Depending on the specific manifestations, severity, and precipitating factors in a depressive episode, one or more of these mental aspects will be affected.

The Five Virtues and other Correspondences of the Five Phases

Any human quality, mental attribution, or emotional experience can be attributed to the five phases. For example, each of the five spirits has a primary responsibility for a particular virtue (Kaptchuk 2000). Shen, which resides in the heart and corresponds to fire, is responsible for ceremony and propriety (li). ‘Propriety ensures that correct behavior fosters timely interactions and relationships’ (Kaptchuk 2000, p. 64). Hun, which resides in the liver and corresponds to wood, is responsi-ble for human kindness and benevolence (ren): ‘it has an intimate rela-tionship to a person’s capacity to feel and endure pain’ (Kaptchuk 2000, p. 61). In the spleen resides the yi, which corresponds to earth and is responsible for ‘faithfulness, loyalty or sincerity (xin) and has the task of enabling and supporting new manifestations to come into being’ (Kaptchuk 2000, p. 60). Zhi, which resides in the kidneys and corresponds to water, is responsible for the virtue of wisdom (zhi): ‘a knowing that has to do with learning to have a relationship to what is unknown and what is unknowable … a deep trust that the unknown eventually reveals an inevitable destiny’ (Kaptchuk 2000, p. 62-63). In the lungs, which correspond to metal, resides the po. The po is respon-sible for the virtue of preciousness (bao). ‘The Po is said to capture the perfection and completeness of a single moment or a short time span’ (Kaptchuk 2000, p. 65).

In Chinese Medicine, virtue refers to impulse from which all things manifest through the movement of qi (Larre & Rochat de la Vallée 1995). In the Ling Shu, it is said: ‘Heaven in me is Virtue. Earth in me is Breaths. Virtue flows, Breaths spread out, and there is Life’ (Larre & Rochat de la Vallée 1991a, p. 87). In the human being, `virtue is the authenticity of the heart as it moves along’, ‘through virtue one both finds and possesses oneself, and ‘virtue gives authen-ticity to the one that possesses virtue’ (Larre & Rochat de la Vallee 1995). For a more complete interpretation of the five phases, their correspondences, and their clinical application, refer to the numerous books of Claude Larre & Elisabeth Rochat de la Vallée, such as The Seven Emotions and Rooted in Spirit, and to Harriette Beinfield & Efrem Korngold’s Between Heaven and Earth and to Lonny S. Jarrett’s Nourishing Destiny.