The Chinese Medical Diagnosis and Treatment of Bipolar Disorder

The Chinese Medical Diagnosis and Treatment of Bipolar Disorder


The Chinese Medical Diagnosis and Treatment of Bipolar Disorder, by Effi Kfir L.Ac


It's difficult to find any mention of bipolar disorder in the Chinese medical literature, particularly in the older classics. While there are abundant references to mania (kuang) and depression (dian) as separate entities, it is hard to find a clear description of a disorder involving mood swings between the two

While chapter 22 of the Ling Shu is titled "DianKuang," this chapter is really about mania, not depression; its description of dian being more suggestive of epilepsy than a mood disorder

We are left with the impression that the authors of the Nei Jing were much more concerned with mania than with depression, perhaps because of its more destructive manifestations. It is perhaps because of this that they never felt the need to describe a combined syndrome of manic depression

The Chinese description of mania refers to a patient with abnormally outgoing, aggressive and excited behavior; who is easily angered, with a tendency to talk loudly or shout. The body movements are restless and forceful, and in extreme cases, the patient may strike things or even expose themselves in public. This is pretty close to the Western descriptions of the manic stage of bipolar disorder


In the case of depression, the behavior is the opposite: quiet, withdrawn, a low voice, and being untalkative, easily frightened or saddened. In extreme cases, patients may close themselves away from all social contact or mutter to themselves incoherently. In the simplest sense, we can say that mania belongs to yang and depression belongs to yin

In spite of their obvious differences, mania and depression are both disorders of the spirit mind (shen zhi), and so it is possible in some cases for the two conditions to share the same etiology. Both mania and depression can be caused by excess emotions, for example. This is an important concept. Sometimes emotional disorders are caused by emotions themselves. Even if the root cause of an emotional disorder is physical in nature, extreme emotions can make the condition worse. Chapter 8 of the Ling Shu, for example, states that mania can be caused by extreme anger; by excessive joy, which damages the "inferior mind" (po); and by sadness, which damages the "soul" hun

Another potential cause of both mania and depression is disorder of the heart and liver, the two body organs most responsible for generating emotions

Some etiologies, however, are exclusive to one or the other. Yang heat excess, for example, can give rise to mania by disturbing the shen. Chapter 74 of the Su Wen states, "All mania belongs to fire." This fire is often caused by other pathogens stagnating in the body, such as blood stasis or phlegm, or by extreme emotions such as anger, joy, or even sorrow - the latter emotion causing stagnation which leads to fire

In Clinical Guide to Case Studies, Ye Tian Shi wrote in the Qing dynasty that long-term worry can cause the qi to stagnate, which allows the phlegm to accumulate and "cloud" (hun xiao) the shen, causing depression. According to Ye Tian Shi, therefore, depression is essentially a disorder of yang qi. We can take this a step farther and say that there are two types of yang qi disorder that can lead to depression: excess and deficiency. Depression of yang qi, which we nowadays refer to as liver qi stagnation, is the more excess cause, and the one most often described in Chinese textbooks

Liver stagnation can cause stagnation by itself, or it can combine with phlegm. But depression can also be caused by yang qi deficiency, which leads to an overly yin constitution and an exhausted individual that wants to withdraw from any social contact. Yang qi deficiency can cause depression in and of itself, or it can lead to phlegm accumulation causing the clouding effect described above. These various etiologies are compiled in the table below


Fire transformed from stagnation


Yang qi deficiency (+ / - phlegm)

Yang qi stagnation ( + / - phlegm)


Extreme emotions

Disorders of the liver and heart

It's fairly easy to see how depression might transform into mania. According to Chinese medicine, anything that stagnates can turn into heat; the process is something like the warmth generated in the center of a compost pile. If the disease process causing the depression is yang qi stagnation, the stagnation will eventually transform into heat and this will produce mania - but transformation to excess fire is less likely to happen if the disease process causing the depression is yang qi deficiency. This helps to explain why not all patients with depression develop bipolar disorders; very deficient patients will lack the yang qi necessary to cause transformation to excess fire. If a patient's depression is caused by yang qi deficiency, therefore, additional pathologies are needed to cause mania. If there is phlegm accumulation or food stagnation, for example, transformation to fire may still occur, or the mania can develop directly from extreme emotions as described above

It's a little bit harder to explain how mania might transform into depression. In fact, the process has never been formally described in the Chinese medical literature. Let us offer our own opinion: the extreme yang of the manic state exhausts the body and damages the qi and blood, leading to the relatively yin state of depression. During the manic phase, the patient is extremely active, rarely sleeps, and often goes without eating. It's only a matter of time before the yang qi "runs out" and the patient's spirit is forced back into the more yin state of depression. If the yang qi should become stagnant again, the whole process starts all over again. The result is what modern medicine calls a bipolar disorder

We believe this explains the etiology of bipolar disorder. In the next part we will explain its differential diagnosis and treatment. This chapter will be suitable mostly to practitioners


The TCM Diagnosis and Treatment of Bipolar Disorder, Part Two (not only for practitioners) By Effi Kfir L.Ac

In the first part, we showed how to understand the development of bipolar disorder ("manic-depression") according to TCM. Now we need to explain its treatment. The strategy here is pretty straightforward: You should treat the phase of the disease that is manifesting at the time of treatment. If the patient is in the manic phase, treat mania; if the patient is in the depressive phase, treat depression. Let's take a look at the differential diagnosis breakdown of mania and depression

Diagnosis and Treatment of Manic Phase

Chinese medicine differentiates mania into four distinct patterns: Heart-Liver fire; Phlegm fire harassing the Heart; Yang ming bowel heat; and Blood accumulation - xu xue

1. Heart-Liver Fire

In the case of Heart-Liver fire, the mania comes mixed with insomnia, anger or excess joy. Discriminating signs include headache; red eyes; ringing ears; dizziness; a bitter taste in the mouth; sores in the mouth (a telltale sign of Heart fire); rib-side pain; and a wiry, strong, slippery and rapid pulse. The treatment principle is to drain Heart-Liver fire and calm the spirit

There are three primary formulas that are used to treat this pattern. If Liver fire symptoms such as anger, headache and rib-side pain are more prominent, choose long dan xie gan tang. If Heart fire symptoms such as excess joy (excitability) and mouth sores predominate, then prescribe zhu sha an shen wan. Given the concern over mercury toxicity in the modern world, I recommend you substitute dai zhi shi or ci shi for zhu sha in this last formula

If the overall symptoms are particularly severe, or if there are signs of phlegm fire, use sheng tie luo yin. This formula has the strongest sedative effects of the three. The heaviness of the iron helps to settle the spirit and drain the fire downward. It also contains ingredients such as bei mudan nan xing and chen pi, which transform phlegm. Zhu sha is also an ingredient, and in this case I think you can simply remove it without affecting the formula very much

In the above formulas, you can add da huang, which will greatly improve each formula's ability to immediately calm the patient. This is done only during the first one or two doses; once the patient has settled down, the da huang is no longer necessary

2. Phlegm Fire Harassing the Heart

In the case of phlegm fire harassing the Heart, the differential diagnosis can be a little tricky. Although this is a distinct pattern, sometimes it looks exactly like Heart-Liver fire. The mania symptoms, for example, are very similar: insomnia; restlessness; and an inability to answer questions. Likewise, the pulse of phlegm fire does not distinguish it very well: It is typically rapid, strong and slippery. Sometimes the pulse is wiry, as well - just like Heart-Liver fire

Our advice here is to pay special attention to the tongue. The "textbook" tongue appearance for phlegm fire is a red body with a thick, yellow, greasy coat. Even here, however, you have to be careful. Sometimes phlegm fire damages fluids, causing the coat to become dry instead of greasy

The treatment principle is to clear heat, transform phlegm and calm the spirit. The typical formula for phlegm fire harassing the Heart is sheng tie luo yin. Since this formula is also an option for treating Heart-Liver fire, we can see the two patterns overlap in both appearance and treatment. Once again, you should remove the zhu sha. You can also add da huang to the first dose to enhance the sedative effects

3. Yang Ming Bowel Heat

When it comes to yang ming bowel heat, you need to think of this pattern as more than a febrile disease. While invading warm disease evils can certainly cause a kind of mania when they reach the yang ming bowel, this pattern can also be caused by eating when one is angry, which drives fire into the bowels

Symptoms of the yang ming bowel pattern include mania with pain and distention in the abdomen. The patient, however, may not be fully in touch with the pain he or she is experiencing, so this may not be included as a complaint. It is best to palpate the abdomen to see if pressure elicits discomfort. The tongue has a deep, dry yellow coat, and the pulse is fast, strong and deep

The treatment principle for yang ming bowel heat is to drain fire downward by purging. The main formula is da cheng qi tang. Note that this formula already contains da huang

4. Blood Accumulation

The final cause of mania is blood accumulation (xu xue), a pattern described in the Shang Han Lun. In this case, blood stasis accumulates in the lower burner and transforms into heat, which disturbs the spirit. In addition to mania, the patient will experience strong, cramping lower abdominal pain. This should not be confused with the abdominal pain of yang ming bowel heat, which is felt over the entire abdomen. The patient is restless and thirsty, but the heat signs are not as obvious. The tongue might be purple, with blue or purple spots on the edges. The pulse is strong and rapid. Even though this is a blood stasis pattern, don't expect the pulse to be choppy; excess heat tends to smooth this quality out of a pulse

The treatment principle here is to move blood stasis and drain heat downward. The formula is tao he cheng qi tang. If the mania is particularly severe, you can use di dang tang. Note that both of these formulas contain da huang

The ubiquitous presence of da huang in the above formulas reflects the ancient understanding of mania arising from fire in the stomach channel, as described in chapter 10 of the Ling ShuDa huang calms the spirit by purging the bowels, which strongly drains the fire from the Stomach channel, thereby removing the disturbance from the spirit

Differential Diagnosis and Treatment of Depressive Phase

The depressive phase of bipolar disorder falls into four main patterns: Liver qi stagnation; qi stagnating with phlegm (qi yu tan zu), Heart-Gallbladder qi deficiency; and Heart Spleen disharmony

1. Liver Qi Stagnation

Every acupuncturist is familiar with this pattern. Look for depression; irritability; insomnia; low appetite; rib-side pain; wiry pulse; and so on. If the depression is caused by emotions such as anger or sorrow, they are likely to be repressed and not easily seen in the patient's affect or behavior

There are three different formulas that can be used. If the pattern is one of pure stagnation with no underlying deficiency, then use chai hu shu gan san. If the Spleen and Stomach are involved, with nausea or poor appetite, or if there are signs of qi deficiency, use xiao chai hu tang. If there is Liver-Spleen disharmony with blood deficiency, use xiao yao wan

2. (Qi Stagnating with Phlegm (qi yu tan zu

Look for depression with irritability; insomnia; low appetite; fullness and distention in the stomach and flanks; and digestive disorders. The tongue coat is thick and greasy, and the pulse is slippery and/or wiry. The patient may also complain of "plum stone sensation" in the throat (mei he qi), or there might be some phlegm expectorated from the lungs

The treatment principle is to transform phlegm and regulate the movement of qi. For this pattern, use ban xiao hou po tang. If the phlegm transforms into phlegm-heat, use wen dan tang

3. Heart Gall Bladder Qi Deficiency

The Nei Jing referred to this pattern as "Gallbladder qi deficiency," but nowadays we look at it as primarily a Heart pattern. The depression in this case is characterized primarily by fear and paranoia. There are often no physical symptoms at all. Think of this pattern when you see a depressive patient who is seemingly asymptomatic, whose pulse and tongue signs fall within normal limits, and who does not seem to fit with other Chinese medical patterns

The treatment principle is to tonify the qi and calm the spirit, and the formula is ding zhi wan. If the qi deficiency is mixed with yin deficiency, you can use tian wang bu xin dan

4. Heart Spleen Disharmony

In this pattern, the symptoms simultaneously reflect Heart blood and Spleen qi deficiencies. The depression is mixed with fatigue; insomnia; palpitations; pale complexion; and possibly menstrual irregularity. The pulse is thin and the tongue is pale

The treatment principle is to tonify qi and blood and calm the spirit. The formula is gui pi tang


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