This case study is provided to give a glimpse into the logic structure of the Traditional Chinese Medical or TCM style of professional Asian Medicine.
SUMMARY OF BASIC PATIENT INFORMATION
Age: 31 years old.
Occupation: Court interpreter.
Medical History: 1985 Ectopic pregnancy. Salpingectomy (R). 1989 Vaginitis. Cystitis. Yeast Infection.
Family history of Hypertension (Father). Cirrhosis of liver (Mother). Death of Mother, 1987.
Present Medications: Multivitamins; Multimineral; Ativan (lorazepam); Xanax (aprazolam); Recent course of Septra Note: Ativan & Xanax were discontinued before beginning TCM treatment.
Chief Complaint: Fear and anxiety with churning stomach, tingling sensation in pelvis, weakness in left hand, pain in left heel.
Onset of the chief complaint began 3 weeks prior to the 1st visit to our clinic. The level of anxiety was such that the patient was unable to perform many common routines such as, grocery shopping or driving an automobile. The patient immediately sought medical attention, followed by psychological counseling. The signs and symptoms continued and at the recommendation of a friend, the patient decided to try Traditional Chinese Medicine.
During the patient interview, areas of psychological stress were revealed: 1) The fear of recurring, incapacitating panic attacks; 2) the husband was attending school in a distant city causing periods of long separation. 3) The death of the patient’s mother 2 years ago.
SUMMARY OF THE 10 QUESTIONS
- Chills and Fever: None.
- Perspiration: Cold sweat during anxiety attacks.
- Head and Body (pain or dizziness): Heaviness of the head (like a band around the head). Dizziness during anxiety attacks.
- Urine and Stool: Urine: Urinary tenesmus. Stool: Alternates between loose and dry.
- Diet and Appetite: Appetite generally is good. Anorexia during anxiety attacks. Craves sour foods. Thirst for hot liquids. Note: Bulimic episode 5 years ago.
- Chest and Abdomen (sensations): Respiration is fast and superficial during anxiety attacks. Feeling of obstruction in the throat.
- Eyes and Ears: Blurred vision during anxiety attacks.
- Energy level: Low.
- Sleep: Insomnia with dream disturbed sleep (nightmares).
- Gynecological/ Obstetric: Menarche at age 15. Cycle is irregular. Flow is heavy. Color is pinkish to dark, with some clots. Breast and abdominal distention 2 days prior to period.
REVIEW OF THE PATIENT’S LIFESTYLE AND MEDICAL HISTORY
Lifestyle: The patient exercises infrequently. A nonsmoker. Does not drink alcohol. Moderate caffeine use. The patient’s husband is attending school in a distant city.
Medical History: 1985 Ectopic pregnancy. Salpingectomy (R). 1989 Vaginitis. Cystitis. Yeast Infection.
INITIAL TONGUE AND PULSE READING
Tongue: Pale body. Thin white coat.
Pulse: Thin. Slightly wiry.
WESTERN MEDICAL VIEW OF THE ILLNESS
Emotional stress such as a change in personal relationships, or a fear of losing control of emotional drives (eg. sexual, aggressive, or dependency needs) are common psychological factors. On a physiological level, the signs and symptoms result from the stimulation of the “fight or flight” reaction of the autonomic nervous system by frightening fantasies, impulses, and emotions.
Anatomy and physiology:
Noradrenergic neurotransmitters are important in producing anxiety. The locus ceruleus, located in the 4th ventricle of the brain, with its numerous connecting pathways to the rest of the brain, is thought to be an important mediating center.
Anxiety Neurosis (Generalized Anxiety Disorder; Anxiety Reaction).
Because many of the somatic signs and symptoms are cardiorespiratory in nature (eg. tachycardia, palpitations, precordial pain) it is important to rule out Myocardial Infarction in the diagnosis. Also to be ruled out are hyperthyroidism and pheochromocytoma., a tumor of the sympatho-adrenal system that produces norepinephrine and epinepherine as these share similar signs and symptoms eg. palpitation, apprehension and tingling extremities.
Insight psychotherapy; Supportive psychotherapy; Relaxation techniques; Meditation. Minor tranquilizers; tricyclic antidepressants or MAO inhibitors (monoamine oxidase); Alprazolam; Beta-blockers (propanolol, atenolol); The agents of choice are benzodiazepines. Note: Xanax and Ativan are both benzodiazepines
Possible Side Effects: Benzodiazepines can increase the suicidal tendency in people with depression and can enhance the effects of other CNS depressants. Skin rash, nausea, headache, impaired sexual function and vertigo. Also, drowsiness and ataxia. There are reports of paradoxical effects such as increased levels of anxiety, psychotic episodes and suicidal impulses. Withdrawal symptoms can occur after several months of use.
TRADITIONAL CHINESE MEDICAL DIAGNOSIS
The Shen encompasses man’s emotional and mental aspects. It includes the thought process component of mental function (logic, coherence, etc.), affect (feelings expressed through voice, expression, etc) and mood (a sustained emotion). Through an adequate supply of Yin and Blood, the Heart houses the Shen. If these are deficient the Shen has no root and becomes Disturbed. The patterns of Blood Deficiency, Yin Deficiency or Disturbed Shen may cause anxiety. Conversely, anxiety can injure the Blood, Yin or Shen.
Also, it is said that the Liver governs the emotions, mental balance and conduct. Stagnation of Liver Qi can disrupt the smooth flow of emotions.
Important etiological factors include improper diet or malnourishment, a long duration of anxiety and worry, a busy lifestyle, or severe hemorrhage. Emotional disharmony (eg. frustration, repressed anger, or prolonged resentment) is the main factor in Liver Qi Stagnation.
Diagnoses according to the Eight Principles:
Yin / Interior / Deficiency / Heat
Traditional Chinese Medical Diagnosis:
Insomnia with dream disturbed sleep indicates Disturbed Shen. A thin pulse, pale tongue and low energy are signs of Blood Deficiency. The wiry aspect of the pulse and the “churning stomach” point to the Liver attacking a weak Middle Jiao.
These signs and symptoms together lead to a diagnosis of: Spleen Deficiency leading to Blood Deficiency and Disturbed Shen, with the Liver Attacking the Middle Jiao.
TREATMENT PRINCIPLE AND PLAN
Treatment Principle: Tonify the Spleen in its function of producing Blood. Calm the Shen. Smooth the Liver and protect the Middle Jiao.
St 36 Zusanli Tonifies Spleen. Tonifies Qi and Blood Sp 6 Sanyinjiao Strengthens Spleen, Tonifies Yin and Blood, Smooths Liver Qi Ren 6 Qihai Tonifies and Regulates Qi Pc 6 Neiguan Calms the Shen, Regulates Qi, Luo Point Ht 7 Shenmen Calms the Shen, Source Point Du 20 Baihui Calms the Shen, Lifts the Spirits Ear Shenmen Calms the Shen
St 36, Sp 6, Pc 6, and Ht 7 were needled bilaterally. Ear Shenmen was needled on the right. All needles were Seirin #5. Needles were retained for 20 minutes.
The formula, Gui Pi Tang Chia Wei which strengthens Heart and Spleen, and Calms the Shen. Ingredients:
|Dang Shen||Rx Codonopsis||Tonifies Qi|
|Huang Qi||Rx Astagali||Tonifies Qi and Blood|
|Dang Gui||Rx Angelicae Sinensis||Tonifies Blood|
|Long Yan Rou||Arillus Longanae||Tonifies Spleen and Blood, Calms the Shen|
|Bai Zhu||Rh Atractylodis||Tonifies Spleen, Benefits Qi|
|Mu Xiang||Rx Saussureae||Moves Qi, Strengthens Spleen|
|Fu Ling||Poria Cocos||Strengthens Spleen, Calms the Shen|
|Yuan Zhi||Rx Polygalae||Calms the Shen|
|Suan Zao Ren||Sm Ziziphi Spinosae||Calms the Shen|
|Zhi Gan Cao||Rx Glycyrrhizae, baked||Tonifies Spleen, Harmonizes|
|Da Zao||Fr Ziziphi Jujubae||Tonifies Spleen, Harmonizes|
Added to Gui Pi Tang:
|Sheng Di Huang||Rx Rehmanniae|
Omitted from Gui Pi Tang:
|Sheng Jiang||Zinziberes recens|
Aerobic exercise for at least 30 minutes duration for a minimum of 3 days per week.
Daily relaxation therapy through the use of a stress reduction tape or meditation technique for 20 to 30 minutes every day.
Patient received treatment 2 times per week and reported gradual improvement after each session. The Panic attacks immediately subsided and the patient was able to resume normal activity (drive a car, grocery shop). The patient reported feeling “more calm”.
By the 8th treatment the patient began to exhibit signs of Liver Qi Stagnation (Purple Tongue, Wiry Pulse). To smooth the Liver, Liver 3 was added to the point pattern and a modified Xiao Yao San herbal formula was prescribed.
The symptoms gradually subsided to the point where the chief complaint became focused on dream disturbed sleep.
Treatment is being continued and I believe is important in the patient’s regaining self confidence concerning her emotions.
The patient was very compliant in that she kept her clinic appointments and took her herbs as prescribed. She also followed the recommendations concerning exercise and relaxation therapy.
Conclusions and analysis of diagnosis and treatment: Since diagnosis and treatment in TCM revolve around the chief complaint, the resolving of the chief complaint provides the validation of the diagnosis and treatment. In this case study of Anxiety Neurosis, the patient was relieved of her major symptoms. Therefore, the diagnosis and treatment are labeled as correct. However, some questions are raised by clinical aspects of this case. The 2 Doctors supervising this patient arrived at differing diagnosis, one choosing to emphasis the Liver Qi tendencies (wiry pulse and nervousness) the other the Blood Deficiency aspects (pale tongue, insomnia). Despite this contrast in diagnosis and treatment, the patient steadily improved. How would we explain the improvement?
Was the improvement due to psychogenic factors? Is this a case of emphasizing the Biao (Manifestation) in one diagnosis and the Ben (Root) in the other, as both could reduce the symptoms? Could a homeostatic response be produced irrespective of diagnosis?
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