Session 13

Lecture – Psychological and psychiatric 3 –

Bipolar disorder
Chinese Medicine
Biomedical perspective: bipolar disorder
Affects 2% of world’s population.
Onset common in young adults. Misdiagnosis and mixed
diagnosis is common.
Spectrum between severe, elevated and excitable mood states
(mania) to dysphoria, low energy and depressive episodes.
Clinical manifestations vary markedly between and within
individuals across their lifespan.
Depressive episodes usually more common than mania or
hypomania – often primary reason seeking treatment.
Lithium considered most effective drug. Mood stabilising
anticonvulsants and antipsychotic medications. Full
remission rare.
(Bobo, 2017; Goes, 2023; Huang et al., 2022)
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Biomedical perspective: bipolar disorder
Mania – 7+ days duration – severe impairment in
social or occupational functioning DIGFAST criteria
(from DSM-V)
Hypomania – 4+ days duration – no marked
disruptions in daily functioning. Distractibility

Both require at least 3-4 of DIGFAST present Impulsivity / Indiscretion

throughout episodes. Grandiosity

Bipolar I – one episode of mania Flight of ideas (racing

thoughts)
Bipolar II – one episode hypomania and one major
Activity (goal directed)
depressive episode increase
Differential diagnosis challenging – post traumatic Sleep (decreased need)
stress disorder (PTSD) and borderline
Talkativeness
personality disorder (BPD) share similar
features with Bipolar. Comorbidity is common.
(Huang et al., 2022)
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Biomedical perspective: bipolar disorder

Psychotherapy important, especially in depressive episodes.

Cause attributed to multiple factors: genetics, psychological
functioning, brain networks, social, biological and environmental
factors.
Family history of bipolar is strongest risk factor 60-80% (twin &
adoption studies) but is not a complete explanation. Diet, trauma,
emotional stress also contribute.
Comorbidity is varied and complex – anxiety, attentional disorders,
personality disorders, substance abuse.
Consistent average rate of recurrence 0.40 – 0.44 episodes per year.
4+ manic, hypomanic or depressive episodes within a 12-month
period is termed ‘rapid cycling’.
(Bobo, 2017; Goes, 2023; Huang et al., 2022; Maciocia, 2009)
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Bipolar disorder: special testing, imaging, investigations

Mood disorders questionnaire (based on DSM-IV criteria for

hypomania)
Hypomania checklist (HCL-32)
World Health Organisation (WHO) Composite International
Diagnostic Interview (CIDI)
Clinical evaluation

(Goes, 2023; Huang et al., 2022)

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Bipolar disorder: Red flags & referrals

Consider diminished capacity to give informed

consent. You may need consent from a
parent, carer, guardian or substitute decision- The National Institute
maker. for Health and Care
Excellence (NICE)
Consider practitioner and patient safety (violent provides
& aggressive behaviour, suicide risk) comprehensive clinical
guidelines for the
Psychiatric referral indicated – urgency depends
assessment and
on the degree to which the patient is a safety management of bipolar
threat to themselves and others. An acute disorder for both
exacerbation of symptoms (mania or severe primary and secondary
depression) warrants an urgent referral, as health care providers.
does the degree or change in the nature of
risk to self or others.

(Anzaldua, 2010; Chinese Medicine Board Ahpra, 2022)

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Chinese medicine perspective: Diān Kuáng

Oscillating periods of Yin depression and Yang mania -

‘dullness and raving’.
Yin excess phase (Diān): excessive gloominess, despair, self-
persecution, self-loathing and blame, suicide risk.
Yang excess phase (Kuáng): elevated mood, energy,
stimulation, agitation, restlessness, impulsivity, sleepless,
delusions/hallucinations, euphoria, aggressive, violent.
Different terms across resources: ‘Withdrawal mania’, bipolar
disorder, manic depression.
Deep Heart crack in tongue indicates tendency to
mental/emotional problems.
(Maciocia, 2009; Maclean et al., 2018; Shi & Zeng, 2011)
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Chinese medicine perspective: Diān Kuáng

Diān Kuáng is not a direct translation for Bipolar disorder.

Components may reflect anxiety, depression, psychosis,
attention disorders, schizophrenia and historically, epilepsy.
Diān is not the same as Yù Zhèng.
Many Yù Zhèng patterns do not include Phlegm (obstruction of
mind).
The distinguishing feature between Diān Kuáng and Yù Zhèng
is the presence of Phlegm.
Phlegm characteristics: loss of insight & self-awareness due to
obstruction of the Mind’s orifices. In later stages, Blood
stasis can also contribute to obstruction of the Mind’s
orifices.
(Maciocia, 2009; Maclean et al., 2018)
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Chinese medicine perspective: Diān Kuáng

Phlegm is responsible for severe clinical

manifestations and is notoriously difficult Phlegm forms from:
to treat.
Spleen deficiency
The tendency to Phlegm or Spleen/Kidney
deficiency may be inherited. Qi stagnation –
obstruction of Qi free
Acute stage Diān and Kuáng (treat branch) flow in Triple Energiser
Resolve Phlegm, open the Mind’s orifices.
Fire – condenses body
Between attacks (treat root) fluids

Diān: Tonify Qi & Blood, move Qi, resolve Blood stasis (from Qi
Phlegm stagnation) aggravates
Phlegm.
Kuáng: Tonify Yin or Blood, clear Empty
Heat.
(Maciocia, 2009; Maclean et al., 2018)
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Chinese medicine aetiology: Diān Kuáng

“Coming and going of the Ethereal Soul” – psychic

manifestation of the free flow of Liver Qi.
Inspiration, creativity, planning, dreams & aspirations.
According to Maciocia (2009), the excessive “coming and
going” is the essential pathology of Kuáng and the Diān
phase is merely a reaction to Kuáng.
Andreasen (2022) provides some insightful commentary on the
relationship between creativity, mental health and treatment
interventions (non-TCM).

(Maciocia, 2009)
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Chinese medicine aetiology: Diān Kuáng

Constitutional factors

Emotional factors

Poor diet, medication, drugs

Trauma

(Maciocia, 2009; Maclean et al., 2018; Shi & Zeng, 2011)

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Diān Kuáng: Chinese medicine pathogenesis
Figure 1

Phlegm component of withdrawal mania

Spleen & Kidney
Constitution deficiency
Overeating,
rich/greasy
foods, alcohol Impedes fluid movement

Constrains Qi and fluids Blocks Qi & Blood

Stress Phlegm Blood stasis

Qi & Phlegm Heat/Fire Yin deficiency

with Phlegm
Emotional,
dietary, drug
Gradually triggers Heart & Liver
weakens Phlegm-fire
Spleen
Fire
Phlegm-fire

Qi & Blood
deficiency Note. Adapted from Clinical handbook of internal
medicine: The treatment of disease with traditional
Chinese medicine (p. 1538), by W. Maclean, J.
Qi deficiency Lyttleton, M. Bayley & K. Taylor, 2018, Eastland
Press. Copyright 2018 by William Maclean.
& Phlegm 13

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Diān Kuáng: Chinese medicine diagnosis
Table 1
Diagnosis
Phlegm & Qi constraint
Depressed, gloomy, withdrawn.
Dull or indifferent affect. Slow
mental processes. Incoherent or
irrational speech; muttering.
Prone to excess or irrational
worry, anxiety, brooding, self-
blame & persecution.
Stifling sensation in chest; much
sighing. No appetite, nausea or
vomiting of saliva-like
substance.
Greasy, white tongue coat.
Wiry & slippery pulse.
Note. Adapted from Clinical Handbook of Internal Medicine: The treatment of disease with traditional Chinese medicine (2nd. Ed.)
(p. 1536 - 1542) by W. Maclean, J. Lyttleton, M. Bayley and K. Taylor, 2018, Eastland Press. Copyright 2018 by William Maclean.
Qi deficiency with Phlegm
Complete unresponsiveness.
Slow mental processes,
confused or chaotic,
visual/auditory hallucinations if
severe. Incoherent speech;
muttering. Prone to excess or
irrational worry, anxiety,
brooding, self-blame &
persecution.
Tend to be pale, weak, clammy
& easily breathless. Minimal
appetite.
Pale, swollen & scalloped
tongue with a greasy, white coat. tongue with a thin coat.
Fine & weak pulse.
CMCM311 CHINESE MEDICINE DEPARTMENT / 12-10-2023 © Endeavour College of Natural Health
Heart & Spleen deficiency
Chronic depression and
withdrawal. Minimal speech /
movement – trance-like. Sorrow,
lamentation, self-recrimination,
frequent crying. Severe –
delusional thinking,
hallucinations, suicidal thoughts.
Nervous, anxious, fearful. Prone
to palpitations, easily startled,
memory problems.
Ashen complexion, lips & nail
beds. Dream disturbed sleep
(nightmare). No appetite, loose
stools.
Pale, swollen & scalloped
Deep, fine & weak pulse.
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Diān Kuáng: Chinese medicine treatment
Table 2

Diagnosis
Phlegm & Qi constraint Qi deficiency with Phlegm Heart & Spleen deficiency

TP: Regulate Qi & relieve
constraint. Transform & eliminate
Phlegm and open the orifices.
GV20, Sì Shén Cōng, GV26,
BL15, BL18, BL20, HT7, PC6,
PC5, ST40, ST36, KI1
Auricular: Shén mén, adrenal,
brain stem, endocrine, heart, liver
TP: Strengthen the Spleen and TP: Strengthen the Spleen, tonify
tonify Qi. Transform & eliminate Qi and Blood. Nourish the Heart
Phlegm to open the orifices. and calm the Shén.
GV20, Sì Shén Cōng, GV26, GV20, Sì Shén Cōng, GV26,
CV12, BL15, BL18, BL20, HT7, CV12, HT7, PC6, SP6, ST36,
PC6, PC5, ST40, ST36, SP6 ST40, BL15, BL20. Palpitations
(HT5), dreams (BL42).
Auricular: Shén mén, adrenal, brain stem, endocrine, heart, point zero,
spleen

Patients taking Lithium or other antipsychotics – encourage to continue medication. Suicide real risk. Avoid
alcohol and non-prescription drugs.

Qi regulating and Phlegm Qi regulating and Phlegm Spleen nourishing, Qi & Blood
transforming diet essential. transforming diet essential. tonifying diet essential.
Greater the deficiency, the longer Greater the deficiency, the longer
the course of treatment. the course of treatment.

Xiao Yao San Di Tan Tang Yang Xin Tang

Di Tan Tang Si Jun Zi Tang
Note. Adapted from Clinical Handbook of Internal Medicine: The treatment of disease with traditional Chinese medicine (2nd. Ed.)
(p. 1536 - 1542) by W. Maclean, J. Lyttleton, M. Bayley and K. Taylor, 2018, Eastland Press. Copyright 2018 by William Maclean. 15

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Diān Kuáng: Chinese medicine diagnosis
Table 3 Phlegm Fire can evolve from Heart & Liver Fire. Phlegm
Fire – mania is more developed (Phlegm obstructs Heart
Diagnosis orifices = delusional thinking). Both damage Yin over time.

Heart & Liver Fire Phlegm Fire Blood and Phlegm Stasis
affecting the Pericardium

Early phase acute episode. Mania (abrupt onset) preceded Mania, insomnia, uneasy,
Unusual self-confidence, by increasing irritability, or odd / restless, auditory or visual
talkative, grandiose. Hyperactive, rash behaviour, headache, hallucinations, easily startled.
insomnia, quick mood changes insomnia. Hyperactivity, Apprehensive, suspicious,
(violence, aggression), restless delusions, hallucinations, paranoid. Talkative or nonsense
agitation, manic, compulsive or aggressive, violent. Exhibit muttering.
reckless behaviour. abnormal physical strength.
Red face & eyes, flushed Red face & eyes, flushed Dark, blotchy complexion,
complexion. Scorched smell. complexion. Scorched smell. vascular abnormalities, skin
Palpitations, tachycardia, mouth discolouration, fixed pain.
and tongue ulcers. Dark,
concentrated urine, constipation.
Red tongue, very red tip & sides, Scarlet red tongue with thick, Purple tongue with purple or
red petechiae. Thick, dark yellow yellow greasy coat. brown stasis spots, dark
or brown, dry or greasy coat. distended sublingual veins.
Slippery, rapid, strong, surging Slippery, rapid, strong, surging Fine & choppy pulse.
pulse. pulse.
Note. Adapted from Clinical Handbook of Internal Medicine: The treatment of disease with traditional Chinese medicine (2nd. Ed.)
(p. 1543-1547) by W. Maclean, J. Lyttleton, M. Bayley and K. Taylor, 2018, Eastland Press. Copyright 2018 by William Maclean. 16

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Diān Kuáng: Chinese medicine treatment
Table 4

Diagnosis
Heart & Liver Fire
TP: Clear Fire from the Heart and
Liver. Sedate the Hún & Shén.
GV20, Sì Shén Cōng, HT8, HT9,
SI3, LI11, LI4, GB34, ST40, LR2
Phlegm Fire Blood and Phlegm Stasis
affecting the Pericardium
TP: Sedate the Heart, eliminate TP: Invigorate Blood, disperse
Phlegm. Purge Heart & Liver stasis. Promote Qi & Blood flow
Fire. through collaterals.
GV26, Sì Shén Cōng, HT7, LI11, PC4, PC6, PC7, HT7, ST44,
ST40, SI3, Shí Xuān SP6, SI3.

Auricular: Shén Mén, sympathetic, brain stem, endocrine, heart, liver

Response to treatment depends Do not treat in this phase. Patient Most chronic cases will have a
on early intervention. Treatment should continue with medications. component of this pattern.
not appropriate if patient is Responds well to treatment for
aggressive or delusional. mood stabilising.
Avoidance of alcohol, drugs, Qi & Blood regulating diet
stress. Heat-clearing diet essential. Continue medications.
essential. Continue medications.
Dang Gui Long Hui Wan Shen Tie Luo Yin Ding Kuang Zhu Yu Tang
Xun Long Qu Hu Tang Long Dan Xie Gan Wan Xue Fu Zhu Yu Wan
Wen Dan Tang
Chai Hu Long Gu Mu Li Tang
Note. Adapted from Clinical Handbook of Internal Medicine: The treatment of disease with traditional Chinese medicine (2nd. Ed.) 17
(p. 1543-1547) by W. Maclean, J. Lyttleton, M. Bayley and K. Taylor, 2018, Eastland Press. Copyright 2018 by William Maclean.

CMCM311 CHINESE MEDICINE DEPARTMENT / 12-10-2023 © Endeavour College of Natural Health

Diān Kuáng: Point selection

Sun Si Miao’s 13 ghost points

Ghost palace GV26 Ghost bed ST6

Ghost message LU11 Ghost market CV24
Ghost eye SP1 Ghost cave PC8
Ghost heart PC7 Ghost hall GV23
Ghost road BL62 Ghost hiding CV1
Ghost pillow GV16 Ghost minister LI11
Ghost seal Haiquan

(Maciocia, 2009)
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Diān Kuáng: Point selection

Pericardium points have a stronger effect on opening the

Mind’s orifices than do the Heart points.

PC7 – calm Shén, settle Hún – treats mania.

PC8 – clear Fire
PC5 – resolves Phlegm from the Mind

(Maciocia, 2009)
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Case Study
Female, age 45, bipolar 10 years.
Onset – after birth of 3rd child.
Manic phases - grossly increased energy and productivity, mental
restlessness, euphoric mood, rapid & excessive speech, spending
sprees, delusional thinking. Severe – bordering psychosis – at times
believed KGB was shadowing her.
Lithium taken inconsistently.
Thin body type, haunted/gaunt face, red complexion on cheek bones.
Tongue: red with particularly red sides, swollen, sticky but rootless yellow
coating.
Pulse: fine & rapid.
What is her diagnosis? Explain the pathogenesis.

(Maciocia, 2009)
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Research

Matsuura et al. (2022) single-arm longitudinal study examining the effect of

acupuncture on physical symptoms and quality of life of patients with
Major Depressive Disorder (MDD) and Bipolar Disorder (BP).
Acupuncture 12 weeks + regular treatment in outpatient clinic. (n=36).
Fixed acupoints + individualised treatment.
GV20, GB20, PC6, LI4, ST36, SP6, LR3, BL15, BL18, BL20 fixed points.
Outcome measures: Himorogi Self-Rating Depression Scale (HSDS) and
Himorogi Self-Rating Anxiety Scale (HSAS), Somatic Symptom Scale-8
(SSS-8) and Visual Analog Scale (VAS) for physical pain, gastrointestinal
symptoms and sleep disorders. Quality of life measured by 8-item Short-
Form Health Survey (SF-8).
Significant improvement in HSDS, HSAS, SSS-8 and VAS post acupuncture
treatment plan. Within the SF-8, bodily pain, general health perception,
emotional health and mental health increased significantly.
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 Chinese Medicine Library Resource Links

APA 7th Edition Referencing Guide reference tips with examples

APA 7 FAQs questions submitted by students with examples provided by librarians
Chinese Medicine Library Guides

Databases, Journals & Web Links:

Anatomy TV
Natural Medicines
Journal of Chinese Medicine Article Archive
A Manual of Acupuncture [App]
Chinese Medicine Formula Image Database

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References

Andreasen, N. C. (2022). The relationship between creativity and mood disorders. Dialogues in Clinical Neuroscience, 10(2),

251-255. https://doi.org/10.31887/DCNS.2008.10.2/ncandreasen

Anzaldua, D. (2010). An acupuncturist’s guide to medical red flags & referrals. Blue Poppy Press.

Bobo, W. V. (2017). The diagnosis and management of bipolar I and II disorders: Clinical practice update. Mayo Clinic

Proceedings, 92(10), 1532-1551. https://doi.org/10.1016/j.mayocp.2017.06.022

Chinese Medicine Board Ahpra. (2022, June 29). Codes and Guidelines. https://www.chinesemedicineboard.gov.au/Codes-

Guidelines.aspx

Goes, F. S. (2023). Diagnosis and management of bipolar disorders. BMJ, 2023(381), e073591. https://doi.org/10.1136/bmj-

2022-073591

Huang, H., Nissen, N., Lim, C. T., Gören, J. L., Spottswood, M. & Huang, H. (2022). Treating bipolar disorder in primary care:

Diagnosis, pharmacology, and management. International Journal of General Medicine, 15, 8299-8314.

https://doi.org/10.2147/IJGM.S386875

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References

Maciocia, G. (2009). The psyche in Chinese medicine: Treatment of emotional and mental disharmonies with acupuncture and

Chinese herbs. Churchill Livingstone Elsevier.

Maclean, W., Lyttleton, J., Bayley, M. & Taylor, K. (2018). Clinical handbook of internal medicine: The treatment of disease with

traditional Chinese medicine. Eastland Press.

Matsuura, Y., Hongo, S., Taniguchi, H., Yasuno, F., Sakai, T. (2022). Effect of acupuncture on physical symptoms and quality of

life in treatment-resistant major depressive disorder and bipolar disorder: A single-arm longitudinal study. Journal of

Acupuncture Meridian Studies, 15(6), 336-346. https://doi.org/10.51507/j.jams.2022.15.6.336

National Institute for Health and Care Excellence (NICE). (2023, December 21). Bipolar disorder: assessment and

management. Retrieved January 31, 2024, from https://www.nice.org.uk/guidance/cg185

Shi, A. & Zeng, D. (2011). Internal medicine: Essentials of Chinese medicine (2nd ed.). Bridge Publishing Group.

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