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Running Header: LIVER IMBALANCES AND THE EMOTION

Liver Imbalances and the Emotion Correlation

Wendy “Violetta” Marie Myers

Psychophysiology (MBM 5640)

Patrick Steffen, PhD, BCB

Saybrook University

July 28, 2018

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Abstract

Chronic Liver Disease (CLD) is becoming one of the most chronic health issues within our

society, but many are unaware of the significance of the preventative measures, risk-reducing

actions, and the emotional manifestations related to their pathological symptoms. Within this

literature review, one study specifically researches CLD patient attitudes and beliefs in relation

to CLD which directly affect and reflect their liver health. One other direct research study is

explored with an association found between depression and CLD as well as three literature

reviews exploring the positive connection between non-alcoholic liver disorder (NAFLD) and

depression, mood disorders, fatigue, and stress in connection with liver imbalances. Within the

studies, participants participated in questionnaires, focus groups, verbal fluency task (VFT),

near-infrared spectroscopy (NIRS), measurement of immune cell-related biochemicals and

proteins, psychiatric interviews, standardized rating instruments, multivariate regression analysis,

proton magnetic-resonance spectroscopy, and PET scans. Using the macroscopic guidelines and

research studies of Traditional Chinese Medicine (TCM) in comparison with Western allopathic

medicine’s microscopic view, this literature review reveals the correlation between two types of

healing medicine modules that are actually explaining the same concept but with different

perspectives. Knowledge of the emotional manifestation of liver health imbalances can help

those with CLD or those on the verge of acquiring CLD learn to equate these with signs of

impending liver disease and liver imbalance. Further, knowledge of how emotions such as

suppressed anger or anger in excess and how it can affect the health of the liver also would

benefit the public.

Keywords: liver, CLD, NAFLD, imbalance, emotions, mood disorders, behavior

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Liver disease, much like cancer and other illnesses to include suicide, is on the rise

whether it be Non-Alcohol Fatty Liver Disease (NAFLD), Alcohol Liver Disease (ALD),

fibrosis or cirrhosis. In our society, many individuals are ignorant of how or why they acquired

these liver diseases.

Liu, Shu, Tu, Zhang, and Hong (2017) peer-reviewed journal article highlight much of

how TCM’s view of liver health correlates with Western medicine and forms the outline of this

literature review. While there is much knowledge to be absorbed from Liu et al.’s literature

review on TCM peer-reviewed research studies and wisdom from the centuries old healing

practice of TCM, it is unfortunate that most of the original resources cited are difficult to find on

due to publication in Chinese language.

Overall Focus and Hypothesis

In this literature review, the structure is defined by the corresponding relationship

between TCM’s view of the liver, emotions, functions, spirit and imbalances and Western

medicine’s view of the liver as it relates, with emphasis on the emotional connection. This

literature review endeavors to show how TCM and Western medicine are often talking about the

same thing but with a different language and a different perspective. Western allopathic

medicine offers understanding on the microscopic level and TCM offers insight on the overall

macroscopic holistic health level on the connection between negative emotions and liver health.

The information is both informing and fascinating and would likely help one understand the

broader place that the Liver holds with all aspects of our health.
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Western and Eastern Views of the Liver, Liver Functions, Spirit and Emotions

Anatomical Liver View

According to Liu, Shu, Tu, Zhang, and Hong (2017), the liver is located beneath the

diaphragm in the upper right quadrant, weighs on average 1.23-1.45 kg in male adults and 1.10-

1.30 kg in female adults, and decreases in size by 100 g every year after the age of 60.

Interestingly, TCM completed a study on the effect of aging on the liver in correlation with

Western studies and showed that after the age of 50, there is a depletion in liver qi (energy), the

liver lobes thin out, bile production decreases, and vision deteriorates further (Liu et al., 2017).

In a more broadly defined definition, TCM views the liver as an abstract concept

connected to the anatomical liver which subsequently connects to the five viscera to include the

eyes, tendons and bones, internal organs (via meridians), distinct physiological mechanisms and

pathological imbalances which harmoniously interact with other Zang-Fu organs (Liu et al.,

2017).

Liver Functions, Spirituality and Emotions

Liver functions end Emotions.

Stress in the form of chronic inflammation can greatly affect the liver’s

function which in the microscopic Western allopathic medicine’s view, is to filter all the

toxins out of the body’s system. Additionally, Liu et al. (2017) described how Western

allopathic medicine views the liver only as an anatomical organ without the inclusion of

the related organ and system functions.

Macroscopically, Liu et al. (2017) explain that TCM, a 2000-year old method of

healing, sees the larger more holistic view of liver imbalances (disease) as stagnation of

the liver. According to Liu et al., in TCM, the liver is responsible for dispersing
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(circulation) of the blood to the body, “dredging” of the system, digestive strength and

absorption, circulation and maintenance of qi, the regulation of emotions (Wei et al.,

2018), blood and bodily fluid and the reproductive function (p.40). Wei et al. (2018)

explain that since the liver stores the blood and the “blood stores the soul,” both qi and

blood form the foundation of emotional activities and regulate these through blood

dispersion, qi production and qi activity (p.2).

According to TCM, since the liver meridian is connected to the eyes, dry eyes and

blurred vision can indicate liver imbalance involving insufficient nourishment from liver

blood (Liu et al., 2017). Liu (2017) further relates how dry, brittle, and deformed nail

plates such as vertical ridges on the nails also indicates insufficient liver blood.

In TCM, the liver is most directly tied with the emotion of anger which can

disrupt the function of the liver if in excess while insufficient dispersion and dredging of

blood by the liver can lead to the emotion of irritability which is an emotion that stems

from anger (Liu et al., 2017).

Liver function of storing blood.

Liu et al. (2017) shared that in the Western view, the liver contains hepatic

sinusoids which equates to the storage of blood in the liver. According to

Western medicine, ¼ of cardiac output is from hepatic (liver) blood flow where in

a prone horizontal position, venous liver blood returns at an increased rate of 50%

(Liu et al., 2017). This is why the liver functions to restrict venous return to the

heart and safeguarding cardiopulmonary function by relieving the heart’s burden

(Liu et al., 2017). The liver stores and produces blood in the embryo. In adults if

the liver is not functioning correctly to store the blood, adults can acquire anemia
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or iron deficiency where the liver is only partly able to store and produce blood

(Liu et al., 2017). Further, Liu et al. described how people with wiry pulses are

correlated with liver imbalance while a moderate or slippery pulse is a normal.

Circulation and dredging.

Liu et al. (2017) related that numerous studies have connected the liver to

the neuro-endocrine-immune network where the liver governs qi-blood activities

through the nerves and endocrine system which is similar to Western allopathic

medicine’s view in which the liver is in charge of the metabolic function of the

body.

Likewise, the dispersion (circulation) and dredging of blood in TCM

closely ties into Western allopathic medicine’s view of the liver as in charge of

water metabolism and reproductive function along with absorption and digestion

(Liu et al., 2017).

Liver spirituality.

Spiritually, TCM addresses how the liver “houses the hun” which is each person’s

spiritual consciousness that is integrally tied to psychological and spiritual dynamics of

an individual. In more detail, Liu et al. (2017) described how the hun is the vibrant spark

within all people that wants to live life to the fullest by motivating people to participate in

their passions and highest desires. This spirit or shen reveals itself with an individual’s

use of “intelligence, spirituality, intuition, dreams, introspection, creativity, imagination,

respect, love and enthusiasm for life, ideas and speech” (p.41).
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Liver care.

Resting the liver is stressed in TCM theory with the advice to sleep before 11 pm

as the qi and blood are the most active during this time within the liver and gallbladder

meridians (Liu et al., 2017). Accordingly, Liu et al. (2017) explained that if the liver fails

to get rest during this time, the liver will not absorb enough nourishment from the blood

and will not store blood effectively or hun spirits (Liu et al., 2017). When the liver is

imbalanced from incorrect sleeping patterns and other dietary, stress, and psychological

issues, an individual will become irritable and easily distracted or scattered (Liu et al.,

2017).

Also, Liu et al. (2017) referred to the importance of a bland diet, getting enough

sleep, getting to sleep by 11 pm during the liver and gall bladder self-healing time (until 3

a.m.), the importance of often closing the eyes for spiritual nourishment which prevents

overuse of eyes, and keeping away from cigarettes and alcohol.

Liver Imbalances

TCM and Western Connection

Within TCM understanding and view of liver imbalances, Liver qi stagnation is

pathological disruption in dispersing function of the liver which can lead to depression, one of

several emotions tied to liver imbalances (Wei et al., 2018).

Wei et al. (2018) explained that liver stagnation can reveal itself through depressive

emotions, pain in the chest or flanks and a tendency to sigh often. Liu et al. (2017) described a

few other symptoms that might indicate liver imbalances within the body. It is important to

observe the condition of the nails which connects to the importance of tendons and fascia. Both

rely on the nourishment of the liver blood with the nail condition reflecting how much liver
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blood is circulating (Liu et al., 2017). According to Liu et al., those with liver disease may show

an increase in melanin in skin cells which reflects in a darker complexion, brown streaks on nail

plates and palms. Additionally, Liu et al. explained how Vitamin D is ties into muscle, tendon

and nail function where bile promotes the absorption of Vitamin D within the large intestine.

Liu et al. (2017) described how the liver is also associated with the production and

storage of Vitamin A and advised eating lamb or pork liver to increase this vitamin with those

who are experiencing nyctalopia and dry eye syndrome. Liu et al. stated that 40% of eye

diseases are related to dysfunction of the liver.

Intriguingly, Liu et al. described a special genetic relationship between the liver and the

eye in the embryonic development where an adult liver tissue transplanted into the blastocyst

cavity forms eyes which likewise supports the TCM concept that the liver is connected to the

eyes. Further, correlations between the existence of meridian phenomena has been shown to

correlate the relationship between meridians and corresponding Zang-Fu organs (Liu et al.,

2017). All of this knowledge can help those with liver disease.

Chronic Liver Disease

Burnham et al. (2014) explained that chronic liver disease (CLD) stems from various

acquired, infectious, toxic, metabolic, and genetic causes. In the long-term, CLD can result in

liver cancer, cirrhosis, and liver failure (Burnham et al., 2014). Several etiologies are associated

in the U.S. with CLD to include: (1) alcohol abuse (2) chronic infections with hepatitis B virus

(HBV) and hepatitis C virus (HCV), (3) biliary track diseases, (4) hemochromatosis, (5)

nonalcoholic fatty liver disease, (6) drug toxicity, (7) autoimmune chronic hepatitis, and (8)

autosomal recessive metabolic diseases -- Wilson’s disease is an example (Burnham et al., 2014).
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NAFLD, which is highly correlated with obesity and diabetes, is the focus of the most concern

due to this diseases recent rise in diagnosis (Burnham et al., 2014).

HBV and HCV are known to be the “silent epidemic” due to the length of time it can take

to be diagnosed with symptoms often showing up decades later (Burnham et al., 2014). This is

like parasites which are also stealthy and can be chronic long-term invaders. Burnham et al.

(2014). related how many diagnosed with HBV or HCV do not always receive treatment due to

the stigma tied to these diseases.

CLD and knowledge, beliefs and attitudes.

Hypothesis.

Burnham et al. (2014) set out in a qualitative study to examine CLD

patients and their knowledge about liver cancer, health behaviors linked to liver

cancer, progression and any barriers to proper liver care.

Participants and Procedure.

Participants were all confirmed diagnosis of CLD, between the age of 18

and 80 years old, and spoke fluent English (Burnham et al., 2014). A total of 13

participants participated in three focus group discussions (Burnham et al., 2014).

Burnham et al. (2014) utilized the Health Belief Model during the focus

group sessions with seven semi-structured questions concerning the participants’

knowledge of liver cancer, perceived susceptibility, severity, barriers to liver

cancer care, preventative actions, and the stigma associated.

Coding networks were setup to reclassify the patients’ responses into

general categories and from this, themes were identified for their HBM constructs

(Burnham et al., 2014).

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Conclusion.

In relating the emotion connection to the liver, interestingly, once some of

the participants found out about their CLD, they were angry which relates to what

TCM says is the most destructive emotion directly tied to the liver and liver

imbalance -- Anger. One participant lamented:

I’m mad. I’m stark-raving-mad, angry, upset, I want to scream, yell, I

want to cry…even though we all know that we’re gonna not live forever,

but when you knowingly have a medical problem it’s like you’ve been

given notice (Burnham et al., 2014, p.740).

According to Burnham et al. (2014), many of the participants were

ashamed of their illness and concealed it to prevent discrimination and gossip.

Additionally, lack of energy was a thread throughout the feedback from

participants in the focus groups (Burnham et al., 2014). As the liver is in charge

of circulating blood throughout the body as well as creating it, this makes sense in

that as TCM states, the liver is only partially dredging (filtering toxins out) and

dispersing (circulating) blood which would likely result in a lethargic condition.

Also, participants had negative attitudes and emotions related to fear and

avoidance with receiving proper liver care (Burnham et al., 2014).

Overall, Burnham et al. (2014) explained that similar to past studies,

participants lacked CLD, Liver cancer, preventative action and risk knowledge

and 75% of the study participants reported engaging in risky behavior.

Interestingly, in the coping study, one of the three categories of studies -- medical
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self-care, behavior change, and coping -- participants stated that they felt

metaphorically that in their combat against HCV, they felt it was like “fighting

battles, waging war, or slaying dragons” (Burnham et al., 2014, p.743). Thoughts

of parasites come to mind as often parasites are difficult to get rid of and cause

chronic health issues which negatively affect the health of the liver which must

deal with their onslaught and daily toxic waste.

NAFLD connection with depression.

Hypothesis.

Many conflicting studies have been published either associating

depression with NAFLD or disproval of any type of connection (Takahashi et al.,

2017). Takahashi et al. (2017) theorize that this is due to differing evaluation

methods for depression. Results from a 336—item Short Form Health Survey

(SF-36) questionnaire and CLD Questionnaire show low quality of life for those

with NAFLD as compared to the general public. Further, Takahashi et al. took

these results to mean that NAFLD patients are depressed without awareness of

being depressed or the diagnosis of.

Takahashi et al. (2017) hypothesize that utilizing NIRS to evaluate brain

activity can differentiate between NAFLD patients and healthy individuals.

Participants and Procedure.

Because the female sex is an independent predictor for depression, 24

Japanese females NAFLD patients were chosen without psychiatric disorders as

well as 15 age-adjusted health females as the control (Takahashi et al., 2017).

Participants were asked to participate in a VFT to estimate oxy-Hb activation

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within the frontal and temporal brain lobes. Takahashi et al. (2017) also asked the

participants to say as many Japanese words as possible with a chosen syllable in

20 seconds for a total of three successive times. Utilizing NIRS measurement,

Takahashi et al. measured concentrations of oxy-Hb and deoxy-Hb with a 52-

channel NIRS system, with two wavelengths (695 and 830 nm) infrared light in

each lobe of the brain. Participants were also given a CES-D questionnaire to

determine their depressive symptoms prior to NIRS measurement with the test

including 20 items about feelings and behaviors (Takahashi et al., 2017).

Conclusion.

Results showed a small increased difference from the NIRS measurement

of cerebral oxy-HB concentration in NAFLD participants in comparison with the

health control group participants (Takahashi et al., 2017). Further in the study,

Takahashi et al. (2017) explained that the patients with NAFLD verbalized a

decreased number of words in the VFT and had decreased oxy-Hb concentrations

during the NIRS measurement, reflecting decreased brain activity and lower

cognitive performance. There seems to be a conflict with the first statement and

the later one regarding oxy-Hb levels which is confusing. In analysis, this study

had some limitations to include: (1) whether NIRS is an appropriate measurement

tool to measure brain activity since NIRS signals during VFT could be measuring

skin blood flow instead (2) sample size was too small (3) sample population was

limited to females (4) no liver histological evaluation of NAFLD patients, and (5)

NIRS had trouble detecting signals in the temporal area due to possible artifacts

(Takahashi et al., 2017).

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Despite this conflicting result, those with NAFLD are living a low-quality

life with sluggish liver function resulting in less circulation of the blood, resulting

in less blood in the brain and therefore less cognitive performance and lowered

moods.

Stress and the liver.

Literature review focus.

Vere, Streba C., Streba L., Ionescue, and Sima (2009) have written a

literature review focusing on the role stress plays in relation to three major liver

hepatic states: viral hepatitis, cirrhosis and hepatocellular carcinoma. In their

literature review, the authors attempted to explain the physiological affect that

stress has on cellular level pathways, immune system effectors and cellular

changes in relationship to the liver (Vere et al., 2009).

Synopsis of Literature Review.

Vere et al. (2009) mentioned several studies that relate stress to both acute

and chronic hepatic dysfunctions involving alteration of the hypothalamic-

pituitary-adrenal (HPA) axis and overall sympathetic dominance related hormonal

results from psychosocial stress (Vere et al., 2009). Vere et al. (2009) explained

that each hormone created by HPA components utilizes different methods of

expressing the immune response as well as the initiation of the immune response.

Conclusion Analysis.

The findings of this literature review study are in congruence with the

various studies they shared relating to the effect of psychosocial stress on hepatic

function. Overall, liver pathologies have a strong effect on the immune system
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and several intra and inter-cellular parts (Vere et al., 2009). Vere et al. feel that

future studies need to focus on testing positive correlations involving raised stress

scores along with serological and imaging parameters that analyze liver disease.

In relation to TCM, since the liver is at the center of all organ function, it

is in charge of qi (energy) production and is said to be the center of all emotions.

As such, stress would most definitely impede liver function. Just as in digestion

in the intestines, the liver must process emotions; the feelings related to stress –

fear, anger, frustration -- if they are chronic in nature, they slow down and

stagnate liver function causing a variety of liver imbalances. According to Wei et

al. (2018), stress can result in both psychological and neuroendocrine responses,

leading to depression, anger, cognitive impairment, panic, anxiety and confusion.

Inflammatory liver diseases, fatigue, and mood disorders.

Literature review focus.

D’Mello and Swain (2014) have written a literature review on the

relationship between inflammatory liver diseases and fatigue and mood disorders.

Interestingly, D’Mello and Swain started out by explaining how the liver is a

barrier between the gut and the body and also how it is constantly subjected to a

low chronic level of endotoxins and dietary antigens through the portal vein.

Three main cytokines are involved in the communication between the peripheral

organ -- the liver and the Central Nervous System (CNS) (D’Mello & Swain).

These include the TNF, IL-1, and IL-6 (D’Mello & Swain, 2014).
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Synopsis of literature review.

D’Mello & Swain’s (2014) studies concentrated on both animal and

human studies in relation to inflammatory liver diseases and mood disorders as

well as fatigue. D’Mello and Swain included studies about the effect of immune

cells or mood disorders, the relationship between raised circulating leukocyte

numbers and mood disorders, changes in 5-HT and Corticotrophin Releasing

Hormone (CRH) along with glutamatergic neurotransmission on mood disorders,

and conversion of Indoleamine 2,3 dioxygenase (IDO) into kynurenine from

tryptophan which facilitates fatigue or depressive behavior.

Conclusion Analysis.

D’Mello and Swain (2014) concluded mentioning in review of the

multiple pathways from the Liver that affect CNS changes. They correctly

concluded from the multiple studies they cited that symptoms such as fatigue,

depression and other mood disorders directly result from inflammatory hepatic

diseases (D’Mello & Swain, 2014). Additionally, the authors included a review

of the multiple anti-adhesion molecules and behavior changes that patients were

treated with in several studies to block the mood disorder and fatigue effects of

cytokines (D’Mello & Swain, 2014). D’Mello and Swain expressed how they

would like to see future studies on the affect that probiotics has on inflammatory

liver diseases and more detailed information on how the periphery communicates

with the CNS.

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According to both Western and TCM medicine, the liver is responsible for

a host of functions within the human body and any form of constant stress such as

inflammatory hepatic diseases reduce the hun, the spark of aliveness in people

and overall qi (energy), often resulting in fatigue and depression.

Depression and chronic liver diseases.

Literature review focus.

Huang, Liu, and Yu (2017) summarized various studies utilizing both

conventional diagnostic criteria and questionnaires to determine if depression is

associated with (CLD). Within the review of the various studies, Huang et al.

developed the hypothesis: Hepatitis C (HCV) directly or indirectly causes

biological alternations of the central nervous system (CNS), directly influencing

psychiatric symptoms.

Synopsis of Methods.

Some methods that Huang et al. (2017) described used studies linking

depression to CLD that included questionnaires such as the BDI-sf, a self-report

screen test for depression, psychiatric interviews, standardized rating instruments,

multivariate regression analysis, proton magnetic-resonance spectroscopy, and

PET scans for microglial/brain macrophage activation.

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Conclusion Analysis.

Huang et al. (2017) concluded with an overview of the multiple risk

factors of depression with CLD involving shared biological pathways and

possible molecular relationships. The authors correctly mentioned each of the

CLD diseases that include HBV, HBC, ALD, and NAFLD and how each of them

correlates with depressive symptoms that can ultimately influence their own

clinical care and their mortality (Huang et al. 2017). Further, there is mention that

most cases of patients with cirrhosis are undiagnosed, suggesting that better

developed studies are needed to determine the effect of depression screening on

CLD management (Huang et al., 2017). Huang et al. (2017) suggested that future

studies focus on larger population CLD. samples that are compared to health

controls and with patients with other long-term disorders.

Within TCM’s view, depression is directly tied to a sluggish functioning

stagnated liver. Literally, this makes sense as stagnation is equated to depressed;

not much movement or activity with everything backing up in the body and in

life.

Awareness of the relationship between depression and liver health as TCM

teaches, would help those with CLD understand where their emotions are

stemming from and perhaps as a result, remove the emotional block they have

from seeking out care.

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Conclusion

While this was a small selection of both direct research and literature overview studies

highlighting the important connection between states of negative emotional health and liver

imbalances, the aim is to help others think outside of the microscopic view of Western allopathic

medicine and to learn to broaden their understanding of liver disease and how it not only causes

physical symptoms but just how those symptoms can manifest as emotions as explained by

TCM.

Knowing the emotional connection between liver disease and resulting or causing

negative emotions can help those not only with preliminary CLD symptoms (borderline) but also

those with CLD change the course of their health. With the knowledge that their liver

imbalances are directly shaping their emotions, individuals might be more likely to make the

necessary changes in their lives to improve their liver health which ultimately will influence their

emotions. This involves not only making physical changes but also recognizing the effects of

not making these changes have on emotions.

While some of the studies reported conflicting results, many more showed a strong

association between negative emotions and Liver imbalances. In summation, further studies are

needed involving: (1) larger sample sizes, (2) isolated variables, (3) utilization of historical

evaluations, (4) measurement of cortisol levels and Heart Rate Variability (HRV) in relation to

liver health, (5) research on how probiotics can influence behavior during CLD, (6) interventions

to improve the quality of life for those with CLD, (7) the use of more than one personality

inventory test, (8) how the periphery nervous system communicates with the CNS, (9) the effect

of depression screening on CLD management, and (10) identification of depression in a in larger

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populations in relation to liver disease (Huang et al., 2017; Burnham et al., 2014; Wei et al.,

2018; D’Mello et al., 2014; Takahashi et al., 2017).

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10.5993/AJHB.38.5.11

D'Mello, C., & Swain, M. G. (2014). Liver-brain interactions in inflammatory liver diseases:

implications for fatigue and mood disorders. Brain, Behavior, And Immunity, 359-20.

doi:10.1016/j.bbi.2013.10.009

Huang, X., Liu, X., & Yu, Y. (2017). Depression and Chronic Liver Diseases: Are There Shared

Underlying Mechanisms? Frontiers in Molecular Neuroscience, 10, 134.

http://doi.org/10.3389/fnmol.2017.00134

Vere, C. C., Streba, C. T., Streba, L. M., Ionescu, A. G., & Sima, F. (2009). Psychosocial stress

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http://doi.org/10.3748/wjg.15.2980

Wei, Y., Wang, T., Wu, H., Yamei, H., Wu,M., Zheng, M., Zhou, R….et al. (March, 2018).

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