Hi again! I want to wrap up the (honestly all-too-)brief comparison I am doing between the biomedical model of psychiatry and that of Chinese medicine. Truthfully, my “comparison” is not super in-depth (I want to say so much more than I can in even 2 blog posts)– and I am clearly biased toward Chinese medicine, given my profession. Moreover, I can confidently call myself an expert in Chinese medicine, whereas I’m not trained in Western psychiatry (despite an avid personal fascination with it). Therefore, while I wanted to make it clear in my last blog post I believe there are many aspects of Western psychiatry that can be very beneficial, I still may not have done the mental health field due justice in outlining potential therapeutic benefits. Anyway, I don’t want this comparison to be an argument for one form of treatment against another: this is about diagnostic models and lenses for approaching treatment decisions which may include varying modalities.
A good place to start is with the concept I mentioned at the end of the last blog, pattern differentiation, or ‘bian zheng’ 辨证 (“bee-en j-uhng”). There is a Chinese saying you may have heard if you are familiar with acupuncture, even if you have not studied Chinese medicine in-depth, that goes, “One pattern, many diseases. One disease, many patterns.” Originally, this saying was not referring to Western disease at all. A Chinese disease in many cases may refer to a Western symptom—i.e. dizziness, abdominal discomfort, insomnia, somnolence—although there are certain Chinese diseases which, when translated, roughly share a common Western disease name— depression, for instance. One major difference between depression as a Chinese disease and as a Western disease is the diagnostic criteria.
So in Western psychiatry, for example, to be diagnosed with ‘major depressive disorder’ or clinical depression, according to the DSM-5 (most recent edition, published in 2013) a patient must meet 5 or more of the following symptoms within a 2-week period, these symptoms must be a change from patient’s previous subjective experience, and at least one symptom must be either depressed mood or loss of sensation/pleasure:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Honestly, it’s been a few years since I last looked at this list. Looking at it now, at the end of my 3-year Masters degree, all I can think is, “….holy $h!*, so many of those are totally different symptoms that could have so many different pathomechanisms—how can just having a collection of THESE symptoms lead to ONE diagnosis, and such a small range of similar pharmacological therapies?” Truthfully, the answer is that Western psychiatry does not have a great lens for understanding the development and cause of depression—which is what the study cited in my last post sheds a little light on.
Did you notice how so many of the qualifying symptoms are related to an individual’s energy? One is directly related to food intake, appetite, and digestion (weight loss or gain), while others are often indirectly related to this (depressed mood, sleep pathologies, psychomotor changes, fatigue, poor focus/concentration, indecisiveness). And this is just how my Chinese medicine brain works now—I can’t help but crawl all over these symptoms individually and collectively, and see how there could be so many potential root causes of this person’s depression! All of these individual symptoms are areas of questioning and observation that Chinese medicine practitioners gather more information about (eating habits, appetite, quality and quantity of sleep, subjective sense of energy). Upon looking at this list of symptoms, I cannot help but start to ask questions about what initial non-invasive steps an individual could take to experiment with how lifestyle factors affect their mood and energy.
People sometimes become uncomfortable when epigenetic (AKA lifestyle) factors are implicated in disease, which is becoming more commonplace as the study of epigenetics (how genes are turned on and off based on interaction with one’s environment) grows. Pointing the finger at lifestyle factors as opposed to genetic factors may make people feel as though they are being blamed for their condition. However this could not be further from the truth! I would like to quote my friend, the poet and photographer Clare Welsh, who responded thoroughly to my last blog post with some of her thoughts as someone going back to school to study psychology:
“There are certain universal mental illnesses: schizophrenia exists in every culture. However, there is research that suggests that this is actually an adaptive disorder the brain develops to protect itself, or even protect against certain cancers, much like the condition of sickle cell anemia was developed by people in warmer climates to protect against the condition of malaria. Taking this view of schizophrenia helps combat stigma. The brain isn’t messed up. The brain is doing what it does in all of us: trying to survive.”
Shifting focus from genetic to epigenetic factors allows for individuals to be empowered by their own sheer ability to change their lives. Many diseases– not just mental-emotional, but musculoskeletal and visceral as well– develop due to the body initially adapting to protect itself against harmful stimuli. Understanding changes in physiology from this perspective allows for patients to connect with the idea that our bodies are NOT static, and chronic conditions CAN change.
Of course, there are many aspects of our society dictating parts of our day-to-day lives which we are unable to change. Unfortunately, we see over and over in clinic that this often leads to the development of disease, primarily as a result of emotional constraint or repression. In TCM, this is understood to be one of the primary causes of depression.
In Chinese medicine, we consider the 7 emotional factors influencing disease to be joy, worry, grief, sadness, anger, fear, and fright (fright differentiated from fear in that fright is more acute and sudden—to be startled rather than to be chronically afraid of something). Chinese Acupuncture and Moxibustion states,
“These are normal emotional responses of the body to external stimuli, and do not normally cause disease. Severe, continuous or abruptly occurring emotional stimuli, however, which surpass the regulative adaptability of the organism, will affect the physiological function of the human body, especially when there is a preexisting oversensitivity to them […] The seven emotional factors […] directly affect the zang-fu organs, qi and blood. For this reason, they are considered to be the main causative factors of endogenous diseases” (page 268).
In all cases, each patient presentation must be evaluated individually to determine the best treatment plan. After a clinician has interviewed the patient, reviewed their medical history, and performed observational and palpatory investigation, the patient’s pattern can be determined. In part, the reason why this diagnostic method works so excellently in clinical practice is that it allows for changes in the treatment plan based on how the patient presents in that moment and what they have experienced since last treatment.
I have a ton more I would like to write about this, but I think this is a good place to stop for now. I have not even begun to discuss the consideration of the Shen, which is 100% essential in TCM psychiatry. There may be a 2-part discussion of the Shen coming up in the not-too-distant future. Meanwhile, I gladly welcome any questions related to this post or the previous post. You can e-mail me at our clinic e-mail or shoot me a message on our clinic FB page. I would love to hear your thoughts. Thanks again for reading!