Mania-and-Withdrawal Most Often Arises from Qi Stagnation
The etiology and pathomechanism of diankuang (withdrawal-and-mania) are complex; in sum, they arise from disorder of zang-fu function and the inner disturbance of heart-spirit by qi, blood, phlegm, and fire. Yet the patients who reach diankuang through qi stagnation are the most common. The pathological scope of qi stagnation is broad, but in clinical experience, liver-qi stagnation is most frequent. So diankuang may be said to begin in the liver and develop through the heart — well worth study.
Growth, development, aging, death, and the onset and unfolding of disease are all tied to qi. The Nanjing · Question 8 says: "Qi is the root of the human; if the root is cut, stem and leaf wither." In the body, qi moves unceasingly through the whole, nowhere absent; ascend-descend-out-in is the basic form of its motion. This motion shows mainly in the activity of the zang-fu and the metabolism of substances: the liver is the qi of growth, ruling free-flow; the heart is the qi of fire-heat, ruling growth-nourishing; the spleen is the qi of grain-and-water, ruling transformation-and-transport; the lung is the qi of clearing-purging, ruling regulation; the kidney is the qi of utmost yin, ruling storage. The liver's rule of free-flow means its qi has a stretching, smoothing regulatory function — regulating the qi of the whole body, regulating the change of emotions, keeping the body's various functional activities in physiologic mutual coordination.
When the qi-mechanism in some region or zang-fu of the body grows unsmooth, producing disorder or obstruction of zang-fu function, it is called qi stagnation. Qi stagnation most often arises from emotional stimulation, dietary disorder, or invasion of outer evil; among these, the emotional cause is most closely tied to the onset of diankuang. When the seven emotions are too sudden, too strong, too prolonged, accumulated worry and brooding pile up, the liver fails to free-flow, and qi stagnation follows. The stagnation affects the spleen-and-stomach; ascending-and-descending lose their rule; phlegm-turbidity rises inside, blocks the heart-orifice, and shrouds the heart-spirit — the person becomes unconscious of others, neglects clothing, speaks of good and ill without regard to kin or stranger. Qi stagnation lingering and turning to fire blazes upward and disturbs the heart-spirit — the patient cannot sit or lie still, sleeps fitfully, has dry mouth and tongue, constipation and red urine. Qi stagnation with blood-stasis, long-stagnant turning to rage, brings beating and cursing — strength beyond the usual. Women often have late or amenorrheic menses, dark blood with clots, even amenorrhea.
In clinic, the great majority of diankuang patients have a clear emotional trigger — fights, fistfights, broken love, sudden loss of kin, unfair treatment — causing extreme emotional depression and resentment, with qi-mechanism congestion. Excessive emotion injures the five zang; the liver is reached first; liver-qi fails to free-flow, smoothness is lost, qi-mechanism is disordered, qi and blood are thrown out. In clinic one sees patients gloomy, weeping, taciturn, joyless, suspicious, brooding; or irritable, sleepless, dreaming much, beating and cursing — all signs of the liver failing to free-flow.
When liver-qi stagnates, it overflows on the spleen-earth; clear qi cannot rise, turbid qi cannot fall; the food-essence congeals into phlegm and shrouds the heart-spirit. With liver-qi stagnant and unsmooth, blood-stasis cannot move; blood-excess gives anger — needle-prick pain, masses and lumps appear. Long stagnation turning to fire, blazing upward to disturb the heart-spirit — all signs of frantic and excessive movement arise in flocks.
I once analyzed 200 cases of diankuang: of those reaching the condition through qi stagnation producing phlegm, fire, or stasis, 112 cases (56%): 69 cases (34.5%) by qi stagnation with phlegm; 27 (13.5%) by qi stagnation turning to fire; 16 (8%) by qi stagnation with blood-stasis. The remaining 88 (44%) had other causes. This shows that treating diankuang must first consider the pathomechanical feature of qi stagnation; to relieve qi stagnation, one should start with the liver.
Since diankuang begins from qi stagnation and most often, in treatment of this disease one must never forget the great rule of coursing the liver and regulating qi. Not only psychiatrists — physicians of every clinical specialty should do the same. One should also conduct psychological treatment with the patient: "Tell him of his failures, speak of his good, lead him toward what suits him, open up what troubles him" — to help dissolve the cause of qi stagnation.