The Treatment of Psycho-emotional Disorders by Acupuncture: with Particular Reference to the Du Mai

Most acupuncturists will have treated disorders of the shen such as insomnia, epilepsy, manic episodes, depression etc. using points such as Baihui DU-20, Shenting DU-24, Renzhong DU-26, Wangu GB-12, Shenmai BL-62 etc. Such treatments are often powerful and effective, but beg the question of how exactly they affect the shen. As the saying goes "It's all very well in practice, but will it work in theory". This short article, therefore, is mainly concerned with the apparent paradox between the Heart-shen and brainshen traditions in Chinese medicine. It came about as a result of attempting to understand the many psycho-emotional indications found in traditional texts for points of the Du Mai and Bladder channels. This curiosity, prompted us to write to various people whom we consider to have a special understanding and knowledge of Chinese classics and traditions. Of these, Heiner Fruehauf (of the Institute for Traditional Medicine in Portland, Oregon) in particular, responded with a profound overview of the relationship between different traditions within Chinese medicine history and a number of translated quotations from Daoist classics and other historical sources. We are especially indebted to his contribution. Giovanni Maciocia also responded with many useful quotations and an emphasis on the inter-relationship between the Kidneys, jing, brain, Du Mai, Heart and shen. This article, which is intended mainly to draw attention to this subject and promote discussion, is principally therefore a combination of these contributions with the work carried out in preparing the forthcoming Manual of Acupuncture. A careful examination of the indications of the acupuncture points listed in various classical and modern texts reveals that a considerable number of them have been used for the treatment of psycho-emotional disorders. There are important points on every channel, but certain generalisations may be made that are helpful in the selection of suitable points for treatment.
1. Points from the Heart and Pericardium channels are of primary importance since they are directly able to treat the Heart and shen. For example: • Tongli HE-5: groaning and sadness, fear of people, restless zang disorder1, pain and agitation of the Heart, sadness and fright, depressive disorder2, frequent yawning, fright palpitations, pounding of the heart.


¥ Shenmen HE-7: palpitations, fright palpitations, pounding of the heart, insomnia, restless zang disorder, frequent talking during sleep, poor memory, mania-depression disorder3, epilepsy, dementia, desire to laugh, mad laughter, insulting people, sighing, sadness, fear and fright, disorientation, Heart agitation, loss of voice. ¥ Shaofu HE-8: Sadness and worry with diminished qi, fearfulness, fear of people, excessive sighing, plumstone throat, epilepsy. ¥ Shaochong HE-9: palpitations, pounding of the heart, mania-depression disorder, epilepsy, fright epilepsy, excessive sighing, susceptibility to anger, fright and sadness with diminished qi, febrile disease with agitation and restlessness. ¥ Ximen P-4: agitated Heart, insomnia, melancholy, sadness and fear, fear of people, insufficiency of the shen qi, epilepsy. ¥ Jianshi P-5: sudden palpitations, oppression of the chest, apprehensiveness, susceptibility to fright, sudden fright disorder in children4, epilepsy, mania, sudden mania, manic raving, agitation and restlessness, absentmindedness, poor memory, loss of voice, ghost evil. ¥ Neiguan P-6: insomnia, epilepsy, mania, poor memory, fear and fright, loss of wisdom, loss of will, loss of memory following windstroke. ¥ Laogong P-8: epilepsy, mania-depression disorder, fright, sadness, apprehensiveness, susceptibility to anger, restless zang disorder, ceaseless laughter at other's misfortune.

2. Some points of the Small Intestine channel, for example Zhizheng SI-7 (mania-depression disorder, fear and fright, sadness and anxiety, restless zang disorder), also treat disorders of the shen due to the Small Intestine's paired relationship with the Heart. Zhizheng SI-7 is the luo-connecting point of the Small Intestine channel, joining with the Heart channel. This is reflected in its name 'Branch of the Upright', the 'upright' being the Heart channel. The Guide to the Classics of Acupuncture states "the luo-connecting points are located between two channels ... if they are punctured, symptoms of the exteriorly-interiorly related channels can be treated". Zhizheng SI7 has a pronounced effect on regulating and calming the Shen. The Methods of Acupuncture and Moxibustion from the Golden Mirror of Medicine, more specifically recommends Zhizheng SI-7 for "depression and knotting of all the seven emotions".

3. Points from yangming channel are strongly indicated, especially in the treatment of shi-type disorders such as mania and mania-depression disorder. This may be explained by four factors: i. points of the Stomach channel, for example Fenglong ST-40, are important to resolve phlegm - an important aetiological factor in such disorders, ii. points of the Large Intestine channel are important to clear heat from the body, and it is the combination of phlegm and heat that underlies the most severe manifestations of psycho-emotional disorders; iii. the Stomach Divergent channel enters the Heart, iv. harmonious digestion is considered a precondition for a peaceful shen, and thus the Ling Shu (Chapter 30) states "When the Stomach and Intestines are co-ordinated the five yin organs are peaceful, blood is harmonised and mental activity is stable. The Mind derives from the refined essence of water and food"5. These factors help to explain the following indications: ¥ Yangxi L.I.-5: mania-depression disorder, febrile disease with agitated Heart, manic raving, propensity to laughter, sees ghosts, fright. ¥ Taiyi ST-23: mania-depression disorder, agitation, tongue thrusting, manic walking. ¥ Fenglong ST-40: mania-depression disorder, mad laughter, great happiness, desire to climb to high places and sing, desire to undress and run around, restlessness, sees ghosts, indolence, epilepsy. ¥ Jiexi ST-41: epilepsy, spasm, mania, agitation, sadness and weeping, fright palpitations, Stomach heat with raving, sees ghosts. ¥ Chongyang ST-42: mania-depression disorder, desire to ascend to high places and sing, desire to undress and run around. ¥ Lidui ST-45: excessive dreaming, easily frightened with desire to sleep, insomnia, dizziness, mania-depression disorder, desire to ascend to high places and sing, desire to undress and run around.

4. The Spleen channel connects with the Heart zang and its healthy yun hua function both provides the basis for proper nourishment of the Heart by blood, and ensures proper transportation and transformation of body fluids, thus preventing the formation of phlegm (an important aetiological factor in psycho-emotional disorders) and treating it once arisen. In the case of Gongsun SP-4, two additional factors are notable: i. it is the confluent point of the Chong Mai, which spreads in the chest, and ii. it is the luo-connecting point of the Spleen channel, and it is a unique characteristic of the luo-connecting points of the yin channels (Lieque LU-7, Tongli HE-5, Dazhong KID-4, Neiguan P-6 and Ligou LIV-5) that they have important effects on psycho-emotional disorders. ¥ Yinbai SP-1: agitation, sighing, susceptibility to melancholy, mania-depression disorder, excessive dreaming, insomnia, chronic fright wind, corpse collapse. ¥ Gongsun SP-4: mania-depression disorder, manic talking with much drinking, insomnia and restlessness, Heart pain, Gall Bladder deficiency, much sighing. ¥ Shangqiu SP-5: mania-depression disorder, agitation with thirst, excessive thinking, propensity to laughter,

nightmares, melancholy Heart, chronic, childhood fright wind, childhood fright epilepsy. ¥ Sanyinjiao SP-6: palpitations, insomnia, Gall Bladder deficiency. ¥ Daheng SP-15: susceptibility to sadness, sighing.

5. Certain points from the Lung channel are indicated, either because of their effect on the po/corporeal soul (e.g. Tianfu LU-3), or because their influence on the zong/ gathering qi helps resolve blood stasis and consequent malnourishment of the Heart and shen (e.g. Taiyuan LU-9). ¥ Tianfu LU-3: somnolence, insomnia, sadness, weeping, absent-minded and forgetful, floating corpse ghost-talk6, melancholy crying ghost talk. ¥ Taiyuan LU-9: agitation with Heart pain accompanied by choppy pulse, manic raving.

6. Points from the Kidney channel are indicated for their ability to nourish yin and harmonise and cool Heart fire (e.g. Taixi KID-3 and Zhaohai KID-6), to root upward rebellion of fire, yang and wind (e.g. Yongquan KID-1) or to treat the zhi/will power (e.g. Dazhong KID-4). For example: ¥ Yongquan KID-1: agitation, insomnia, poor memory, inability to speak, susceptibility to fear, anger with desire to kill people, mania-depression disorder, loss of voice. ¥ Taixi KID-3: insomnia, excessive dreaming, poor memory. ¥ Dazhong KID-4: palpitations, agitation, dementia, somnolence, tendency to anger, fear and fright, susceptibility to fear, desire to close the door and remain at home. ¥ Zhaohai KID-6: insomnia, somnolence, night-time epilepsy, sadness, fright, nightmares.

7. Points of the Gall Bladder and Liver channels are indicated for psycho-emotional disorders characterised by stagnation of qi and its subsequent transformation into heat which may rise to disturb the Heart, and for disorders of the hun/ethereal soul (e.g. insomnia and fear). It is interesting, however, to note that a point such as Taichong LIV-3 which is much used in modern practice for treating disorders such as depression, irritability, frustration etc. has very few indications of this sort in either traditional or modern texts. ¥ Zhejin GB-23: sighing and tendency to sadness, insomnia, heat in the lower abdomen. ¥ Riyue GB-24: sighing and tendency to sadness, heat in the lower abdomen. ¥ Zuqiaoyin GB-44: nightmares, insomnia, agitation and restlessness, agitation and heat of the hands and feet. ¥ Xingjian LIV-2: tendency to anger, sadness, susceptibility to fright, madness, insomnia, palpitations, epilepsy. ¥ Ligou LIV-5: plumstone throat, depression, much belching, fright palpitations, fear and fright. ¥ Zhangmen LIV-13: agitation and heat with a dry mouth, tendency to anger, susceptibility to fear, insomnia, manic walking, epilepsy, depression with inability to take a satisfactory breath.

8. The back-shu7 and front-mu points, as well as certain points of the Du Mai, are indicated in the treatment of various psycho-emotional disorders, principally due to their action on their corresponding zang or fu, for example:

¥ Xinshu BL-15: poor memory, anxiety, weeping with grief, insomnia, excessive dreaming, not speaking for years, heart xu frightened and watchful (cautious), delayed speech development, mania-depression disorder, epilepsy, dementia, mad walking, anxious and depressed sensation in the chest with inability to take a satisfactory breath. ¥ Ganshu BL-18: much anger, mania-depression disorder, epilepsy. ¥ Danshu BL-19: fright palpitations with unsound sleep, insomnia. ¥ Gaohuangshu BL-43: poor memory, palpitations, insomnia, phlegm-fire mania. ¥ Jinsuo DU-8: anger injures the Liver, mania, mad walking, much talking, epilepsy, fright epilepsy. ¥ Shendao DU-11: sadness and anxiety with poor memory, fright palpitations, absent-mindedness, timidity with shortness of breath, apprehensiveness, epilepsy. ¥ Shenzhu DU-12: mad walking, delirious raving, sees ghosts, rage with desire to kill people. ¥ Juque REN-14: fright palpitations, poor memory, mania, mania-depression disorder, aversion to fire, tendency to curse and scold others, ranting and raving, anger, epilepsy with foamy vomiting. ¥ • Jiuwei REN-15: the five kinds of epilepsy, mania, mad walking, mad singing, dislikes hearing the sound of voices.

IN ADDITION TO the points listed above, whose indications can be explained by their action on qi, blood, phlegm, shen, hun, po and zhi, there is another group of points which demand a quite different explanation. These are points on (or affecting) channels which enter the brain i.e. points of the Du Mai and Bladder channels, and points located on the head and neck. For example: ¥ Houxi SI-3: epilepsy, mania-depression disorder. ¥ Tianzhu BL-10: mania, ceaseless talking, sees ghosts, epilepsy, childhood epilepsy. ¥ Shenmai BL-62: mania-depression disorder, palpitations, insomnia. ¥ Yuzhen BL-9: madness, manic walking, epilepsy. ¥ Wangu GB-12: epilepsy, mania, mental agitation, insomnia. ¥ Changqiang DU-1: mania, fright epilepsy, mad walking. ¥ Fengfu DU-16: mania, ceaseless talking, mad walking and desire to commit suicide, sadness and fear with fright palpitations. ¥ Baihui DU-20: fright palpitations, poor memory, lack of mental vigour, inability to choose words, absentmindedness, much crying, sadness and crying with desire to die, wind epilepsy, mania. ¥ Shenting DU-24: mania-depression disorder, ascends to high places and sings, discards clothing and runs around, mimics other people's speech, fright palpitations, insomnia, loss of consciousness, tongue thrusting8. ¥ Renzhong DU-26: mania-depression disorder, epilepsy, inappropriate laughter, unexpected laughter and crying, speaking without awareness of a person's high or low status, ghost attack.

There is indeed an apparent contradiction here within Chinese medicine theory. The concept that the shen is stored in the Heart is of course an axiom of Chinese medicine theory and is attested to in various classics, for example the Ling Shu: "The Heart controls the vessels; the vessels are the residence of the shen 9". "When the blood and qi are already in harmony, the ying and wei already communicating, the five zang already formed, the shen will reside in the Heart10. "The Heart is the great master of the five zang and six fu and the residence of the jing shen11"; and the Su Wen: "The Heart stores the shen12". At the same time, there are many classical references to the concept of the shen being stored in the head and brain, for example the Su Wen: "the head is the residence of the intelligence13" the Xiuzhen Shishu: "The brain is the ancestor of the body's form and the meeting place of the 100 shen14" the Neijing (not Inner Canon but Daoist Internal Mirror)15: "The brain is the ancestral portal of the body, the capital where the 10,000 shen meet" Sun Si Miao, in the 1000 Ducats: "The head is the supreme leader, the place where man's shen concentrates" Li Shi Zhen: "The brain is the residence of the original shen" the Ben Cao Bei Yao 16: "All of a person's memory resides in the brain". Three main factors may help to illuminate this theoretical difficulty: i. different traditions within Chinese medicine, ii. the influence of modern medicine, and iii. the interrelationship of the Heart, blood, jing, brain and shen. Different traditions within Chinese medicine Both before and after the appearance of the Neijing, different traditions are apparent within the broad fields of Chinese medicine, spiritual practice and health preservation. In pre-Neijing times, a more structural perception of the human body placed the brain as the main organ in charge of mental activity17. From the Neijing onwards, when the study of medicine diverged and grew more independent of its Daoist roots, a more functional view of the body developed, based on the predominance of the five zang and six fu and their correspondences (especially five phase correspondences), the brain being 'relegated' to the status of an extra fu, and the Heart becoming the sovereign of the body and the residence of the shen. This divergence is reflected in the Neijing which says I understand that there are some Daoists who have a completely different understanding of the nature of a zang and a fu. Some say the brain and the marrow are zang ... whereas others think of them as fu. If presented with a view other than their own, they insist that only their own interpretation is right18. Later esoteric Daoist texts strongly influenced certain great doctors of the Tang, Yuan and Ming dynasties such as Sun Simiao, Zhang Jingyue and Li Shizhen19, and their understanding of the role of the brain, and the principal acupuncture channel which influences it, the Du Mai,

again entered the corpus of Chinese medicine theory. At the same time, none of these doctors challenged the theory of the Heart-shen as being essentially contradictory to the brain-shen theory. The influence of modern medicine During the Qing dynasty and the Republican era, knowledge of Western anatomy began to infiltrate China. One author who is considered to have been influenced by these developments was Wang Qingren20 who in the chapter 'On the Brain' (in Correcting the Errors of Medicine 1830) stated "intelligence and memory rely on the brain". Wang's book was published and distributed along with A New Treatise on Anatomy, a translation of basic Western medicine texts by an English medical missionary Benjamin Hobson and his assistant Chen Xiutang. The inter-relationship of the Heart, Kidneys, Jing, brain and Shen. All aspects of the human organism derive from the coming together of the jing of the parents. The Ling Shu says: "Life comes about through the jing; when the two jing (of mother and father) unite, they form the shen21". Zhang Jie Bin says: "The two jing, one yin and one yang, unite ... to form life; the jing of mother and father unite to form the shen22". In other words the pre-natal jing, derived from the parents, is the origin of the existence of the human being and the original source of the shen. As far as zangfu theory is concerned, it is the Kidneys which store jing, and at the same time produce marrow and fill up the brain. Thus the Ling Shu states: "The brain is the Sea of Marrow23". This is the meaning, therefore, of the statements by Li Shizhen: "The brain is the residence of the original shen". and Yangxing Yanming Lu: "Shen, that is jing. If we can preserve jing, then the shen will be bright; if shen is bright, there will be long life24". Other authors have stressed the relationship between the brain and the Heart, which is another reflection of the vital relationship between the Heart and Kidneys, fire and water. The Leizheng Zhizai25 says: "The shen of the human being resides in the Heart, and the Heart's jing relies entirely on the Kidney. Thus, the brain is the store house of the original shen, the sea of jing marrow, and this is where memory comes from". The Daoist classic Ling Jian Zi26 stated: "The Qi of the Heart is connected with the Niwan Palace above". 'Niwan' ('Sticky Pellet' or 'Mud Ball Palace'), is also known as 'Huangting' (The Yellow Palace). The Niwan in the Daoist tradition is the central one of the nine palaces of the brain where all the various shen meet, and is considered to be the location of the material basis of the shen. Niwan is discussed in various Daoist classics, for example: "The origin of jing-shen in the brain is also called Niwan27". "The entire shen that expresses in the face has its origin in Niwan"27. "At the top of the human body, there is Tiangu Niwan, this is the where the shen is stored ... Tiangu, that is the Original Palace, the residence of the Original Shen, where mental and spiritual brightness exists, the most important aspect of Shen" 28. It is the extraordinary channel, the Du Mai, which serves as the link between the Kidneys, Heart and brain. Four pathways are classically described for this channel. Its first originates in the lower abdomen, emerges at the perineum, runs posteriorly along the midline of the sacrum and the interior of the spinal column to Fengfu DU-16 at the nape of the neck, enters the brain, ascends to the vertex, descends along the midline of the head to the bridge of the nose and the philtrum and terminates at the junction of the upper lip and the gum. Its second pathway originates in the lower abdomen, descends to the perineum, winds around the anus, ascends the interior of the spinal column and enters the Kidneys. Its third pathway originates in the lower abdomen, ascends to the middle of the umbilicus, passes through the Heart, ascends to the throat, winds around the mouth and ascends to below the middle of the eye. Its fourth pathway emerges at Jingming BL-1, follows the Bladder channel bilaterally along the forehead, the bilateral branches converge at the vertex and enter the brain, the single channel emerges at Fengfu DU-16 and divides again, descending through Dazhu BL11 and Fengmen BL-12 along either side of the spine to the Kidneys. This linkage of the Heart and brain was referred to by Cheng Xing Gan who said: "When Marrow is full, thinking is clear. Too much thinking leads to Heart fire which burns the brain ... the Marrow is rooted in the jing and connects downwards with the Du Mai; when the ming men warms and nourishes, the marrow is full". In conclusion, therefore, the Du Mai is the channel that mediates between the brain and the Heart. Clinically many of its points may be used to treat a variety of psycho-emotional disorders, in much the same way that points of the twelve principal channels may be used, especially those of the Heart and Pericardium. If we try and be more precise about the use of the Du Mai points, we can suggest that a) their indications generally reflect shi patters of Shen disharmony such as mania-depression disorder, and b) they are especially indicated when psycho-emotional disorders are accompanied by fullness and discomfort of the head, dizziness, disturbance of consciousness and epilepsy. Notes
1. An episodic mental disorder most commonly occurring in women characterised by a variety of possible symptoms such as agitation, restlessness, oppression of the chest, disturbed sleep, irritability, rash and impetuous behaviour, abnormal speech, frequent yawning and stretching, disorientation, worry, grief, weeping, sighing and even convulsions without complete loss of consciousness. Generally considered to be due to emotional frustration which impairs the smooth flow of Liver qi or worry which injures Heart yin, accompanied by blood defi

ciency. Historically this condition was also associated specifically with blood deficiency of the uterus, drawing parallels with the origin of the Western concept of hysteria which is how zang zao is sometimes translated.

2. Dian.

3. Dian-Kuang.

4. This term first appeared in the 1000 Ducats. It is due to weakness or immaturity of the shen qi in a child who suddenly sees a strange person or a strange object, or hears a strange noise. This gives rise to fright and weeping, and in extreme cases changes in the childs's complexion. Wind-phlegm, generated by the shock, combine and further disrupt the Spleen and Stomach giving rise to vomiting, diarrhoea and abdominal pain and ultimately to clonic spasm. 'Sudden fright disorder in children' is similar in meaning to 'fright epilepsy'.

5. Translated by Giovanni Maciocia, The Practice of Chinese Medicine, Churchill Livingstone p. 198, where shen is translated as Mind.

6. The exact meaning of this term is unclear but it seems to refer to raving or nonsensical speech, perhaps due to possession. Sun Si Miao in his 1000 Ducats refers to 'melancholy crying ghost talk' in relation to this point. Linda C. Koo in Nourishment of Life, Health in Chinese Society (The Commercial Press, Hong Kong p. 123), a contemporary book on Chinese folk beliefs says in discussion of ghost possession "In cases where the ghost's (i.e. evil spirit's) influence was the result of a gradual process, the victim would initially be sad, sensitive, and withdrawn. As the ghost's powers over the victim's mind became stronger, he would begin to behave as if he were in a dream, talk about ghostly matters, or act as if he were conversing with ghosts".

7. It is interesting that despite their evocative names, the points Pohu BL-42, Shentang BL-44, Hunmen BL-47, Yishe BL-49 and Zhishi BL-52 are notable for the absence of any psycho-emotional indications, with the exception of 'three corpse possession disorder' for Pohu BL-42.

8. The tongue is repeatedly thrust out of the mouth, up and down, left and right, like a snake's tongue. It is differentiated into Spleen and Heart Shi heat, Spleen and Kidney Xu heat, and is also seen in epilepsy.

9. Chapter 8.

10. Chapter 54.

11. Chapter 71.

12. Chapter 62.

13. Chapter 17.

14. Ten Works on Practice Toward the Attainment of Truth, a Qigong compendium in 64 volumes from the Qing dynasty; editor and exact date of publication unknown. This text combines important Daoist works on qigong practice from the Sui, Tang and Song dynasties, including the Huangting Neijing Jing (see note 27 below).

15. Written by Liu Sijing around 1647, part of the work Che Sheng Ba Bian elaborating on the workings of the human body - the other parts are about the stars, the sun, the moon etc.)

16. Essentials of Materia Medica by Wang Ang (1694).

17. For example Guanzi one of the Daoist classics which discusses topics of philosophy, medicine and other realms

of science. Heiner Fruehauf comments: "Guanzi Daoism is typical of the pre-Neijing type of scientific writing where the so called Daojia thinkers (different from the later Daojiao, a term which signifies religious Daoism) had an animated yet fragmented discourse on the establishment of a scientific code, very similar to the pre-Socratic philosophers in Greece. Just like Aristotle and Plato created the basis of Western scientific thought out of the maze of these much less known thinkers, standard classics such as the Neijing integrated fragmented ideas presented in the Guanzi and other pre-Han dynasty works. Books like the Guanzi for instance, were elemental in standardising the post-Neijing 5 Phase approach. Before Neijing times there were at least 7 different ways of relating the elements to each other)".

18. Chapter 11.

19. Some medical historians, for example B. J. Andrews (JCM No. 36) also hold the opinion that early contact with Jesuit missionaries may have played a part in the revival of the theory of the brain as the centre of consciousness. Wang Qingren in his work 'On the Brain' cited three people who had previously held the same opinion as himself on the brain: Li Shizhen, Jin Sheng and Wang Ang. Jin Sheng was a friend of Jesuit missionaries in the Ming court in the sixteenth century and a convert to Roman Catholicism, whilst Wang Ang was his close colleague.

20. B.J.Andrews (JCM No. 36), however, believes that the influence of Western medicine on Wang Qingren is unproven, and that his refutation of classical Chinese anatomical theories was much influenced by the radical 'evidential research' movement then prevalent amongst Chinese scholars.

21. Chapter 8.

22. Zhang Jie Bin, Classic of Categories (Lei Jing) People's Health Publishing House, Beijing, 1982, p. 49. First published in 1624.

23. Chapter 33.

24. A Record of Nourishing Xing and Extending Ming written by Tao Hongjing 456-536. This was a compilation of different theories on nourishing life in fashion at the time.

25. Differentiation and Treatment of Disease written by Lin Peiqin in 1839 - a medical primer imitating the format of Zhang Shi Yitong (Comprehensive Medicine According to Master Zhang 1695).

26. By Xu Sun of the Jin dynasty. This text mostly discusses the relationship between shen and xing (material form).

27. From Huangting Neijing Jing an often cited Daoist esoteric work that does not seem to have a single author. Its origin is unclear, but it was annotated by Bai Fuzhong around 700. The Daoist nun Hu Yin published several versions around 850.

28. Zheng Li Lun.