Anxiety: The Unsettled Shen
Anxiety is the most common mental complaint in the United States, affecting up to 40 million adults 18 years of age and older. According to the Anxiety and Depression Association of America (ADAA), anxiety disorders are considered very treatable, though less than 40 percent of those suffering anxiety seek medical treatment. Anxiety is attributed to many factors including rapid social change, work stress, financial stress, family and relationship issues, emotional trauma, chronic medical illness, medication side effects, and genetic factors.
The most common approach to the treatment of anxiety in America today is through pharmaceutical medication, therapy, and counseling, or a combination of the two. What is often overlooked is the inter-relationship between body and mind. Recent studies have revealed there are physiological factors that may greatly increase a person's tendency to experience worry and anxiety. If holistic treatment of this complaint is to be undertaken, careful consideration of both the physiology and the psychology is required.
Anxiety is a modern term that is not found in the historical Chinese medical literature. There are four traditional emotional disease entities that may roughly correspond with anxiety. These are:
- Fear and Palpitations (惊 悸 Jīng Jì)
- Panic Throbbing (怔 冲 Zhēng Chōng)
- Mental Restlessness (烦 躁 Fán Zào)
- Agitation (脏 躁 Zàng Zào)
From the view of traditional Chinese medicine, several emotions make up what we presently describe as anxiety. The seven emotions are joy, anger, pensiveness, grief, sorrow, fear and fright/shock. On close examination four emotions stand out as comprising what we call anxiety. Fear certainly is one including fear of the unknown, fear of loss, and fear for one's security and safety. Pensiveness also plays a part. Anxiety leads us to ruminate over the many possible outcomes of a given stressful experience. Grief should also be included as sadness and loss make up part of the experience of anxiety. Finally, anger and resentment should be included, as well. According to TCM theory, the emotions of fear, pensiveness, grief and anger cause the Qi to sink, stagnate, dissipate, and rise respectively. In addition to our directly experiencing unpleasant emotions, exaggerated emotional states may also have an impairing effect on the functions of the organs influenced by those specific emotions. In patients suffering from anxiety long term, it is important to evaluate the health of the Heart, Kidneys, Spleen, Lung and Liver as these organs in particular can be weakened by excessive associated emotions.
Herbal Formulas to Settle the Shen
Ding Zhi San: Settle the Emotions Powder
This formula, attributed to the Tang Dynasty physician Sun Si-Miao, first appeared in Important Formulas Worth a Thousand Gold Ducats. Though commonly translated as Settle the Emotions Powder, the name literally translates as “Settle the Resolve Powder”. This translation provides a clearer view of the therapeutic intent of the formula; it's use isn't merely to calm the emotions, but to strengthen the Heart Qi in order to re-align and balance the Shen of the five Zhang Fu under the guidance of the Heart Shen.
Traditional indications for the formula include apprehensiveness, anxiety, fright, worry, being disheartened, inappropriate laughter, palpitations, restlessness, irritability, confusion, disorientation, forgetfulness, and poor concentration. Often, there is a history of significant emotional shock.
The etiology associated with this formula is Heart Qi deficiency with turbid Phlegm obstructing the Heart. The Heart Qi holds and focuses the Shen of the organs into a coordinated whole. Heart Qi deficiency can manifest as apprehensiveness and a loss of the ability to focus, access, and carry out tasks. Complexity, change, and coordinating activities become difficult to carry out. Fear, disorientation, and apprehension arise, often with palpitations. Obstruction of the Heart Shen can also manifest as diminished memory, forgetfulness, confused speech, feeling disheartened and lacking in inspiration or drive.
Ren shen is the chief herb in this formula, assisted by Tai zi shen. Ren shen powerfully tonifies the Qi of all the Yin organs, especially benefitting the Heart Qi and Shen. The Shen Nong Ben Cao Jing states that Ren shen "...quiets the consciousness, settles the Hun and Po, arrests palpitations with anxiety, opens the Heart and strengthens resolve." Fu ling and Fu shen are the deputies, both quieting the Heart and calming the Shen. These herbs also treat insomnia and forgetfulness due to Heart Qi deficiency or internal obstruction of turbid Phlegm. Yuan zhi and Shi chang pu are spicy, bitter, warm and aromatic, and as assistants reinforce each other's effects. As an important Dui Yao pair these herbs warm, unblock, and free the movement of the Heart Qi, with Yuan zhi releasing emotional constraint, while Shi chang pu opens the orifices, eliminates phlegm and turbid filth, and quiets the Spirit.
Long chi, dragon's teeth, is a modern addition to this classical formulation. Modern materia medica state that it "Settles anxiety and calms the spirit". The Shen Nong Ben Cao Jing states that Long chi treats "madness, mania, running about, and binding Qi below the Heart. It resolves spiritual matters." This herb is often used in formulas in China to treat attention, focus, and cognitive deficiencies. It's sweet, cool and astringent nature is said to be especially efficacious in stilling and quieting hyperactivity of the mind.
Synopsis: This formula specifically treats Heart Qi deficiency causing anxiousness, apprehension, fearfulness and the feeling of being disheartened. The patient may also show signs of confusion and loss of mental focus and resolve.
Contraindications: Early stages of external wind acute illness, and acute toxic heat. Use with caution during pregnancy.
Gan Mai Da Zao Tang: Licorice, Wheat and Jujube DecoctionOriginally described in Essentials from the Golden Cabinet, this important formula is a staple in the Chinese herbal medicine treatment of unsettled Shen. Though humble in its original construction, this prescription stands out as a flexible and broadly applicable treatment for a variety of common emotional and psychological complaints.
The traditional pathology associated with Gan Mai Da Zao Tang is known as Zang Zao, or restless organ disorder. Originally listed in the source text under the heading of 'miscellaneous disorders of women', it was developed to treat patients suffering from recent or recurring blood loss with unsettled Shen. Chapter 11 of Essentials from the Golden Cabinet states "Patients manifesting with pathogenic weeping that causes the Hun and Po to be unsettled are deficient in Qi and Blood. Disorders of Qi and Blood deficiency pertain to the Heart. Patients with Heart Qi deficiency are full of fears."
Gan Mai Da Zao Tang is suitable in treating patients suffering from complaints that are primarily emotional in nature, as well those same complaints that are either precipitated or exacerbated by Qi and Blood deficiency. The primary cause of this condition arises from the Hun and Po losing their ability to be anchored to the body, leading to the patient becoming disconnected from the usual norms of behavior. Heart Qi and Blood are often deficient as well, leading to a loss of the Heart's role in coordinating the Shen of the five Zang Fu and in establishing resolve in thought and behavior. Traditional symptoms include anxiousness, disorientation, impulsiveness, depression, manic behavior, disorientation, and fitful sleep. In the modern clinical setting this formula has broad applications ranging from mild, end-of-the-day stress and worry to recurring bouts of more significant anxiety, excessive rumination, unfounded fear and disturbed sleep patterns.
The original formula was composed of the first three ingredients above. The chief herb is Fu xiao mai, which enters the Heart. Being light, sweet and cool in nature, it treats spontaneous perspiration and night sweats primarily by augmenting the Heart Qi and cooling. According to Convenient Reader of Materia Medica, Fu xiao mai "...eliminates heat from deficiency, cools and inhibits the Heart Yang fluids (perspiration)." Its cooling and light astringing nature also controls the dispersal of the Hun and Po. The deputies in the formula are Gan cao and Da zao. Gan cao nourishes the Heart, tonifies the Qi, and harmonizes the twelve channels, while Da zao augments the Qi and Blood and calms the Shen. Together these three herbs nourish Qi and Blood, secure the Hun and Po, augment the Heart Qi, and quiet the Shen.
In many modern modifications of Gan Mai Da Zao Tang, we find the addition of the last four ingredients shown above. These additions further augment the functions of the three original ingredients. Fu ling prevents stagnation of the Spleen’s fluids while also calming the Shen. Bai he nourishes the Heart Yin and calms the Shen. He huan pi calms the Shen and relieves emotional constraint by regulating the Liver, while Ye jiao teng nourishes the Heart Blood and calms the Shen.
Synopsis: Gan Mai Da Zao Tang is a widely applicable formula for calming the mind and emotions, releasing stress and anxiety, and gently nourishing the Qi and Blood to strengthen clarity and resolve. This formula's strength comes from its gentle nature. Because the formula gently tonifies and calms all twelve organs, it can be used to treat a very broad set of patterns of disharmony.
Contraindications: Contraindicated in excess conditions, early stages of acute external illness and acute infection. Use with caution during pregnancy. Contains wheat.
Bu Nao Pian: Brain Supplementing Tablets
Bu Nao Pian is a modern formulation designed to treat multiple organ deficiency patterns with combined emotional and cognitive complaints. The functions for Bu Nao Pian are to nourish the Heart, tonify the Kidneys, clear and benefit the brain, tonify the Blood, open the Orifices, transform Phlegm, extinguish Wind, subdue Liver Yang, and calm the Shen.
The formula addresses specific emotional and cognitive complaints often found together. The general indication for this unique formulation is Heart Blood and Kidney Essence deficiency with Wind stirring, and Phlegm misting the Heart and obstructing the Shen. This clinical picture can be found in both the young and old alike. Indications for the formula include poor memory, reduced cognitive function, poor concentration, forgetfulness, confusion, disorientation, dulled senses, mental fatigue, restlessness, combined with poor sleep and insomnia, excessive dreaming, nightmares, anxiety, excess rumination, palpitations, and fatigue.
The origin of these complaints come from Kidney Essence deficiency, Blood deficiency, and Phlegm obscuring the Shen. One of the primary functions of the Kidney Essence is to nourish the brain, referred to as the Sea of Marrow. When the Sea of Marrow isn't sufficiently nourished, memory, concentration and cognitive function can be impaired. Blood deficiency can lead to stirring of internal Wind leading to agitation, restlessness, dream disturbed sleep and insomnia. Phlegm misting the Heart can obscure the Shen and produce confusion, insecurity, uneasiness, anxiety, nightmares and disorientation. The causes of this complex picture can be acquired, inherited, or the results of aging.
Bu Nao Wan can be divided into six pairs, plus Wu wei zi. The first pair, Suo yang and Hu tao ren, tonify the Kidney Yang and nourish the Yang aspect of Essence. Dang gui and Gou qi zi nourish Heart and Liver Blood, and tonify the Blood aspect of the Kidney Essence. These four tonic herbs comprise 34% of the formula.
Gou teng and Tian nan xing clear Wind and Phlegm in the channels, with Gou teng also pacifying ascending Liver Yang and quieting the Shen. The heavy anchoring Long chi, along with Hu po, quiet anxiety, arrest tremors and palpitations, and calm the Shen. Bai zi ren and Suan zao ren both nourish the Heart and calm the Shen, with the former being especially useful in nourishing the Heart Yin. The last pair, Yuan zhi and Shi chang pu, are a particularly noteworthy Dui Yao pair. Both herbs are bitter, spicy and warm and enter the Heart. Shi chang pu's spicy and aromatic quality facilitates opening the orifices, disseminating the Qi, and dispelling Phlegm in order to clear the Heart. Yuan zhi's bitter warmth expels phlegm, calms the Shen and augments the mind. Finally, Wu wei zi has a special role in this formula as it ties the formula together. It's sweet, sour and astringing quality tonifies the Kidneys, secures the Essence, quiets the Shen and secures the Heart Qi. The overarching pathology that this herbal formula addresses is one of dispersed vitality of the Qi, Blood, Essence and Shen.
Synopsis: This herbal formula nourishes the Sea of Marrow (brain), while also clearing Wind and calming the Shen. It is ideally suited for older patients with diminished cognitive capacity, and patients of all ages with diminished memory, reduced cognitive clarity, attention deficit, physical and mental fatigue, and anxiety rooted in Qi, Blood and Essence deficiency.
Contraindications: Pregnancy, early stages of acute external illness, and acute infection.
In conclusion, anxiety is a common complaint treated in TCM clinics. It is essential to determine at the outset of treatment if the patient's condition is primarily a result of physiological or emotional causes. If both etiologies are present, then determine which of the two was the initial cause, and address both simultaneously. It is particularly important to understand that it is difficult to treat emotionally based anxiety by simply addressing the physiology.
Mark W. Frost, MSTCM, L.Ac. is chair of the Herbal Medicine Department at the American College of Traditional Chinese Medicine in San Francisco, California. Professor Frost teaches in both the Masters and Doctoral Programs, serves as a clinical supervisor in colleges Community Clinic, and has had a private practice in San Francisco for over 30 years. He is the author of numerous articles on Chinese herbal medicine and has presented at several TCM conferences since 2014.