Thursday, November 1, 2012

FOCUS ON A REMEDY: SOOTHE THE SHEN

SOOTHE THE SHEN

Soothe the Shen is a new remedy that complements the existing mental-emotional remedies: it treats depression and/or anxiety. It is based on a variation of two separate formulae: Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction and Bai He Zhi Mu Tang Lilium-Anemarrhaena Decoction.

The ingredients of Soothe the Shen are as follows:

Zhi Gan Cao Radix Glycyrrhizae uralensis preparata
Fu Xiao Mai Fructus Tritici levis
Da Zao Fructus Jujubae
Zhi Mu Radix Anemarrhaenae
Bai He Bulbus Lilii
Dang Gui Radix Angelicae sinensis
Wu Wei Zi Fructus Schisandrae
He Huan Pi Cortex Albiziae
Yuan Zhi Radix Polygalae
Fo Shou Fructus Citri sarcodactylis
Suan Zao Ren Semen Ziziphi spinosae

Actions: tonifies Qi, nourishes Blood and Yin, moves Qi, opens the Mind's orifices.
Patterns: Qi, Blood and/or Yin deficiency, Qi stagnation.
Indications
Depression, sadness, anxiety, mental confusion, poor memory, tiredness, poor appetite, scanty periods.
Tongue: Pale or normal. In case of Yin deficiency: no coating.
Pulse: Weak, Choppy or Floating-Empty.

Classical antecedent
Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction and Bai He Zhi Mu Tang Lilium-Anemarrhaena Decoction.

Explanation
The classical indications for Gan Mai Da Zao Tang Glycyrrhiza-Triticum-Jujuba Decoction are: disorientation, melancholy, crying, inability to control oneself, restless sleep, night sweating, sighing. This formula is found in Zhang Zhong Jing's Jin Gui Yao Lue of AD 220 AD. It is in chapter 22 on women's problems entitled "Pulses and Patterns of Complicated Women's Diseases" (Fu Ren Za Bing Zheng Mai): "Women suffering from anxiety are affected by sadness and crying, they are like lost souls [Shen ling] and yawn frequently: use Gan Mai Da Zao Tang."¹

Interestingly, also the formula Bai He Zhi Mu Tang Lilium-Anemarrhaena Decoction is found in the same classic. This would seem to indicate that mental-emotional problems were as common in those ancient times as they are now. In fact, also the formula Ban Xia Hou Po Tang Pinellia-Magnolia Decoction used for plum-stone syndrome with stagnation of Lung-, Stomach- and Heart-Qi is found in the same classic (this formula is called Open the Heart in the Three Treasures).

There are many different interpretations of the formula Gan Mai Da Zao Tang that is within Soothe the Shen. The prevailing modern view is that this formula is for a condition of Heart-Yin deficiency, Spleen deficiency and Liver-Qi stagnation. In the original text, the formula is for Zang Zao which literally means "visceral agitation".

The rationale usually given for the use of this formula for Liver-Qi stagnation is from chapter 22 of the "Simple Questions" (Su Wen) which says that the sweet taste soothes the Liver (reverse Controlling cycle of the Five Elements). I personally do not use this formula for Liver-Qi stagnation. 

The formula Gan Mai Da Zao Tang naturally tastes very sweet. I personally find this explanation unconvincing and one that reflects the modern Chinese tendency to overemphasize Liver-Qi stagnation. I personally use the formula for patterns of deficiency which may be of Qi, Blood or Yin (not Yang deficiency).

It is an intriguing formula as it has a profound mental effect and yet it is composed of only three apparently mild herbs, two of which are items of food as well as herbs, i.e: black dates, licorice and wheat husks. As it is composed of three very mild herbs none of which individually is known for any profound mental-emotional effect, I call this formula one of the "miraculous" formulae. 

I find this formula excellent when the patient is not only depressed and anxious but also mentally confused and kind of "absent". Often, this can be the result of heavy cannabis use in the past.

I use this formula when these mental-emotional symptoms occur against a background of deficiency of Qi of the Spleen, Heart and Lungs and of Heart-Blood deficiency.

Some doctors in China also use this formula in the treatment of Attention Deficit Hyperactivity Disorder in children.

The second formula Bai He Zhi Mu Tang Lilium-Anemarrhena Decoction is used for the Lilium Syndrome (Bai He Bing) described in the Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue, ca AD 220), chapter 3-1. This syndrome sounds remarkably like the description of a depressed patient.

"The patient wants to eat, but is reluctant to swallow food and unwilling to speak. He or she wants to lie in bed but cannot lie quietly as he or she is restless. He or she wants to walk but is soon tired. Now and then he or she may enjoy eating but cannot tolerate the smell of food. He or she feels cold or hot but without fever or chills, bitter taste or dark urine [i.e. it is not external Wind nor internal Heat]. No drugs are able to cure this syndrome. After taking the medicine the patient may vomit or have diarrhoea. The disease haunts (hu huo) the patient [hu means "fox" and huo means "bewildered"] and, although he or she looks normal, he or she is suffering. The pulse is rapid."²

Modern books describe the symptoms pertaining to this formula as "absent-mindedness, as if in a trance, mental restlessness, bitter taste, anxiety, depression, dark urine, red tongue (which may be without coating), rapid pulse."

The treatment principle recommended by modern doctors is to moisten and nourish the Heart and Lungs, tonify Qi, nourish Yin, clear Heat (or Empty Heat), calm the Shen, strengthen the Zhi (of the Kidneys).

I use this formula primarily when there is a deficiency of Yin of the Heart and Lungs and the patient is anxious and sad. As the formula consists of only two herbs, I frequently add this formula to another formula in any situation when a patient is depressed against a background of a Lung and Heart syndrome, but especially Qi and Yin deficiency of these two organs or Heart-Heat.

The combination of these two herbs is particularly good to treat sadness and grief.

Within Soothe the Shen, Zhi Gan Cao Radix Glycyrrhizae uralensis preparata, Fu Xiao Mai Fructus Tritici levis and Da Zao Fructus Jujubae form the original formula Gan Mai Da Zao Tang to tonify Qi and Blood and calm the Spirit. Fu Xiao Mai is the emperor herb within this formula. Please note that Gan Cao is here not to harmonize but it is a minister herb to tonify Qi and Blood and calm the Spirit. For this reason, it is not in the usual small dose but a higher dose (about 9% of the total).

Zhi Mu and Bai He constitute the formula Bai He Zhi Mu Tang and they are here to nourish Qi and Yin and calm the Spirit; in particular, they treat sadness.

Dang Gui nourishes Blood and calms the Shen. Wu Wei Zi nourishes Yin and calms the Spirit. He Huan Pi, Yuan Zhi and Fo Shou move Qi, open the Mind's orifices and stimulate the movement of the Hun to relieve depression. Suan Zao Ren nourishes Yin, calms the Spirit and settles the Hun to relieve anxiety.

The relationship between Shen of the Heart and Hun of the Liver is all important in the pathology of depression. The Hun gives the Shen inspiration, creativity, ideas, plans, life-dreams, aspirations: this psychic energy is the result of the "coming and going of the Hun" and it is the psychic manifestation of the free flow of Liver-Qi (and in particular, of the physiological ascending of Liver-Qi).

On the other hand, the Shen needs to control the Hun somewhat and to integrate the psychic material deriving from it. It is in the nature of the Hun to "come and go", i.e. it is always searching, it has ideas, inspiration, aims, life-dreams, etc. The Hun is the gui of our human nature and it has its own independent existence.

The Shen needs to integrate the material deriving from the Hun in the general psyche: the Hun is the source of many ideas simultaneously; the Shen can only deal with one at a time. Therefore "control" and "integration" are the key words describing the function of the Shen in relation to the Hun.

When the "coming and going" of the Hun is deficient, there is a lack of inspiration, creativity, ideas, plans, life-dreams, aspirations: this is an important feature of mental depression. It is important to note that the psychic "coming and going" of the Hun may be deficient either because itself is deficient, or because the Shen is over-controlling it. The latter is common in individuals with strong, rigid beliefs ("religious" in a broad sense) which lead the Shen to suppress the psychic ideas coming from the Hun. This situation may also arise as a consequence of guilt.

In depression, there is a disconnection between the Shen of the Heart and the Hun: the Hun lacks its normal "movement" and the person lacks creativity, ideas, imagination and, most of all, plans, projects, life-aims and inspiration so that depression results.

NOTE
Please note that when I use the term "Shen" above, I refer to the Shen of the Heart. When I use the term "Spirit" I refer to the "5 Shens", i.e. the Yi of the Spleen, Zhi of the Kidneys, Hun of the Liver, Po of the Lungs and the Shen itself.

END NOTES
1. He Ren 2005 Essential Prescriptions of the Golden Chest (Jin Gui Yao Lue), People's Health Publishing House, Beijing, p. 83. The Essential Prescriptions of the Golden Chest was written by Zhang Zhong Jing and first published c. AD 220.
2. Essential Prescriptions of the Golden Chest, p. 26.

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