Scholarly article on topic 'Acupuncture treatment of substance-induced psychosis, addiction and pain: A review with case study'

Acupuncture treatment of substance-induced psychosis, addiction and pain: A review with case study Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Tzafrir Nachmani

Abstract Substance-induced psychosis is an extreme mental disorder that is relevant to up to 25% of individuals presenting with first episode of psychosis. One out of three of those continuing the drug abuse will have a recurrent psychosis. In order to treat the psychosis and prevent recurrent drug abuse which might lead to another psychosis, the therapist should understand all parts of the process leading up to psychosis, including the root causes for the drug abuse and the addiction, the effect of the drugs on the body and the psychosis itself. This article reviews substance-induced psychosis and the process leading to the abuse, the addiction and the psychosis from both Western and traditional Chinese medicine and includes three case studies of patients with acute psychosis who were treated successfully.

Academic research paper on topic "Acupuncture treatment of substance-induced psychosis, addiction and pain: A review with case study"

Journal of Traditional Chinese Medical Sciences (2015) 2, 205-214

Acupuncture treatment of substance-induced psychosis, addiction and pain: A review with case study

Tzafrir Nachmani*

The Izun Institute for Addiction and Mental Illnesses, Israel

Received 2 March 2015; accepted 20 May 2015 Available online 31 March 2016

Abstract Substance-induced psychosis is an extreme mental disorder that is relevant to up to 25% of individuals presenting with first episode of psychosis. One out of three of those continuing the drug abuse will have a recurrent psychosis. In order to treat the psychosis and prevent recurrent drug abuse which might lead to another psychosis, the therapist should understand all parts of the process leading up to psychosis, including the root causes for the drug abuse and the addiction, the effect of the drugs on the body and the psychosis itself. This article reviews substance-induced psychosis and the process leading to the abuse, the addiction and the psychosis from both Western and traditional Chinese medicine and includes three case studies of patients with acute psychosis who were treated successfully. © 2015 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).

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KEYWORDS

Psychosis; Substance abuse; Addiction; Dian Kuang

Introduction

Psychotic symptoms are an extreme mental disorder that can lead to admission and it's one of the few disorders that can eventually lead to involuntary admission. One of the triggers to a psychotic episode is substance abuse. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association.1 (pp113) "Between 7% and 25% of individuals presenting with a first episode of

* Tel.: +9725478078. E-mail address: tzafrirna@izun.org.il.

Peer review under responsibility of Beijing University of Chinese Medicine.

psychosis in different settings are reported to have substance/medication-induced psychotic disorder." A 2010 survey by the Center for Disease Control and Prevention found there are about 1.5 million discharges with psychosis as first-listed diagnosis in U.S.A hospitals.2 Using the DSM-5 estimates mentioned above, it is estimated that between 105 000 and 375 000 of these are likely to be due to substance-induced psychosis.

Several studies found that ongoing substance use, in first episode psychosis, is associated with negative outcomes.3-5 In their research, Sara et al found that people with ongoing substance abuse (after first psychosis) had nearly 30% more chances of recurrent psychotic symptoms compared with no drug use. The negative outcome of the ongoing substance abuse

http://dx.doi.Org/10.1016/j.jtcms.2016.02.005

2095-7548/© 2015 Beijing University of Chinese Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

suggests that there is importance in understanding the mechanism connecting drug abuse and psychosis, and using this understanding to help psychotic patients to cease substance use.

Our experience for the last 10 years in the Izun Institute, shows that introducing Chinese medicine (acupuncture and herbs) to the psychotic and addictive patients have had several advantages:

1. Calming the psychotic patient and avoiding unnecessary psychiatry drugs.

2. Reducing the side effects of psychiatric drugs taken by the patient.

3. Reducing withdrawal symptoms.

4. Assisting the addictive patient addressing his addiction and providing him with tools to overcome it.

Although there is no major difference between the symptoms of substance-induced psychotic disorder (SIPD) and other psychosis symptoms (resulting from certain conditions whether physical, mental or related to medication), I will suggest that according to Chinese medicine, substance-induced psychosis has a unique background and mechanism, in the way it affects the body and spirit, which will be discussed hereafter.

In this article, I will discuss the connection between the psychotic symptoms, the preceding substance abuse and addiction and the emotional pain associated with the substance abuse. I will analyze each of these 3 components according to the different models of Chinese medicine and eventually suggest a treatment model that I myself am currently using.

Part One: Modern Medicine

One of the key features of the substance-induced psychosis is the presence of substance intoxication or withdrawal. It's possible to focus on treating the psychotic episode, but as said in the introduction, ongoing substance abuse can lead to recurrent psychosis in 30% of the cases. In light of that, a broader approach is needed and the understanding of the drug and the reasons for addiction is mandatory.

Substance/medication-induced psychotic disorder

Diagnosis:

The key diagnosis criteria by the DSM-5 are:

A. Presence of one or both of the following symptoms:

1. Delusions.a

2. Hallucinations.b

a "Delusions are fixed beliefs that are not amenable to changes in light of conflicting evidence. Their content may include variety of themes ..."1<pp-87>

b "Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. They may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders ..."1<pp-87>

B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

(1)The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.

(2) The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced. Such evidence of an independent psychotic disorder could include the following:

The symptoms preceded the onset of the substance/ medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication: or there is other evidence of an independent non-substance/medication-induced psychotic disorder (e.g., a history of recurrent non-substance/medication-related episodes). Treatment:

The treatment according to The Merck Manual of Diagnosis and Therapy6 should be:

1. Desist the substance intake.

2. Antipsychotics drugs may be used depending on the drug involved. Hallucinogen and phencyclidine psychosis may not respond well to antipsychotics. Acute adverse effects of antipsychotics should be treated according to the symptoms.

3. A supportive approach is preferred, with reassuring, structured, and protective surroundings.

Prognosis:

The disorder usually remits within days or several weeks depending on the drug involved.

The DSM-5 state that some agents have been reported to evoke temporary psychotic states that can sometimes persist for weeks or longer despite removal of the agent and treatment with neuroleptic medication.

Substance abuse and addiction

According to the Merck manual a single definition for drug dependence is elusive. Concepts that aid in defining drug dependence are tolerancec and psychologicald and phys-icale dependence. Addiction, according to the manual is another concept without a consistent, universally accepted definition. The manual refers to addiction as compulsive use and overwhelming involvement with a drug, including

c Tolerance describes the need to progressively increase the drug dose to produce the effect originally achieved with smaller doses.

d Psychologic dependence includes feelings of satisfaction and a desire to repeat the drug experience or to avoid the discontent of not having it. Drugs that cause psychologic dependence often have >1 of the following effects: Reduced anxiety and tension; Elation, euphoria, or other pleasurable mood changes; Feelings of increased mental and physical ability; Altered sensory perception; Changes in behavior.

e Physical dependence is manifested by a withdrawal (abstinence) syndrome, in which untoward physical effects occur when the drug is stopped or when its effect is counteracted by a specific antagonist.

spending an increasing amount of time obtaining the drug, using the drug, or recovering from its effects. It may occur without physical dependence. Addiction implies the risk of harm and the need to stop drug use, regardless of whether the addict understands and agrees.

The American Psychiatric Association finds 7 different classes of addictive drugs that can cause psychotic disorder: Alcohol, Cannabis, Hallucinogens, Inhalants, Sedatives, Stimulants and Others.

The Israeli Anti Drug Association7 divides psychoactive substances to 4 groups by their impact on the user:

1. Suppressants: alcohol, sleeping pills.

2. Hallucinogens: LSD, cannabis, mushrooms, mescaline.

3. Stimulants: amphetamine, cocaine, crack, ecstasy,

caffeine.

4. Narcotics analgesics: opium, heroin, synthetic narcotics.

According to the National Institute of Drug Abuse (NIDA) in U.S.A: "Many people who regularly abuse drugs are also diagnosed with mental disorders and vice versa. The high prevalence of this comorbidity has been documented in multiple national population surveys since the 1980s."8 Another meta-analysis study found that there was an increased risk of any psychotic outcome in individuals who had used cannabis in the past, with greater risk in people who used cannabis most frequently.9

Treatment:

According to NIDA, since addiction is complex illness, medication and behavioral therapy, especially when combined, are important elements of an overall therapeutic approach.

The root of substance abuse and addiction

Substance abuse is present in different degrees in almost all societies at present and in the past.10 Kaufman suggests a theory on the sources of substance abuse "Substance use provides temporary resolution of psychological wounds or pain".11(pp5) Elsewhere he suggests that "substance use is generally initiated during a sever crisis in which an individual's usual adaptive capacities are impaired and narcissistic vulnerability is increased."11 (pp8) — all are what I now refer to as 'the well of pain'. This correlation between substance abuse and trauma, PTSD, and mental and emotional pain is shown in many studies.12-14 The pain that can cause substance use may be the result of a childhood or adolescent experience, it can arise from an exterior event (such as assault) or from psychological development (family system, painful affect intolerance).11(pp4-5) Substance abuse is one among several means the body-spirit utilizes attempting to suppress the pain, restore the body's dynamic balance and survive. (Other means of numbing the pain might be: eating disorders, self-harm and physical injury, or engagement in excessive sexual activity among others).

Part Two: Chinese medicine Substance abuse and pain

According to Yongping,15 substance abuse is a dysfunction of the Heart-Spirit. "... desire comes from the Heart and

belongs to the Spirit. When desire is abnormal, or out of control, it becomes pathological, therefore uncontrollable desire is a dysfunction of the Spirit."

What causes the dysfunction of the Spirit?

According to Kaufman, 11(pp4'5) when trying to translate the reasons for substance abuse and the dysfunction of the spirit into Chinese medicine, one can identify 2 different processes (in some cases they are inseparable):

Family/community-developmental processes (family structure breakdown, poor parent—child relations, lack of values and religions, over or under discipline, painful affect intolerance). In his book Dragon Rises, Red Bird Flies, Dr. Leon Hammer, who is psychiatrist as well as Chinese medicine practitioner, suggests that the Pericardium provides both nourishment and protection to the Spirit and the Heart and it has a role in one of the fundamental issue of a safe contact with other human beings.16(pp188) The triple burner is responsible for socialization within the nuclear family and the 'family of man'.16(pp 209) The Earth element (as part of the five elements/phases) is responsible for formation of bonds and for the formation of trust and self-worth.16(pp215) In all the above situations those three functions and element are harmed causing eventually dysfunction of the Spirit.

Trauma (Post Traumatic Stress Disorder)-single or recurrent: abuse, abandonment, death. In addition, I would add to Kaufman's list trauma from accident, combat or any other life threatening event. These are complex conditions, beyond the scope of this article and deserve their own separate discussion. Dr. Hammer suggests that emotional shock depletes the yin of the Heart, and the ability of qi and blood to either enter or leave the Heart.17 I'm suggesting, in brief, a model for PTSD based on the work of Peter Levine.18 In general terms, trauma is a situation that the body perceives as one that endanger its survival and therefore need to defend itself with the sympathetic nervous system reaction: fight or flight. This external situation impacts first and foremost the Kid—Heart axis. The fear from death depletes the Kidney and represses the Heart. When the fight or flight reaction is suppressed by the cerebral cortex freeze reaction arise, in Levine words the energy gets stuck, there is a stagnation in the Liv—Lu axis. The stagnation in the Liv—Lu axis is responsible for the sympathetic nervous system's symptoms in PTSD and the fight and flight reaction (Wood) is blocked in the body (Metal). In result, the imbalance in the two axes that causes an imbalance is the Earth element that can no longer harmonize the five elements.

At first, life had dug a deep well of pain. Depending on a person's inner and outer resources available, the Spirit in return tries to regain its balance, striving to fill the hole by utilizing every possible mean. When resources are sufficient the system recovers its balance, its mutual generation and control (Sheng and Ke) cycle, and life goes on. However, when resources are scarce, repression mechanisms are required to pitch in and work hard. That is when and where substance abuse comes in.

Psychoactive substances

Substances change the state of mind, consciousness and cognition. Some substances will cause hallucinations, some will stimulate and others will calm.

While addiction is a disease of the Spirit, the substances involved also cause physical damage to the body, and this damage tends to cause even more damage to the Spirit. Because of this, we can say that addiction is a combination of both Spirit damage and physical damage.15

In addition to trauma and injuries that occur in life, the elements and organs suffer further damage caused by substance abuse, having the same effect as the excessive consumption of foods, medicinal remedies and herbs have on the body and on its energetic mechanisms.

Yongping15 categorizes the effect of the substances on the body and Spirit by yin substances and yang substances. Yin and yang, the opposite forces, the former being cold, calming and slowing process, the latter being hot, elating and speeding processes, each has different and even opposing effects on the body, and cause different pathologies (Table 1).

Understanding the substance's yin/yang effect is important on two levels: the first is to understand the mechanism that influences the body/Spirit and the strategy to treat it. The second level is to understand the patient's own experience — what he or she were seeking through the use of substance (For more about this, see Section 2.2 later in this article).

Psychosis

The two main symptoms of psychosis are delusions and/or hallucinations. In both of the symptoms, the consciousness of a psychotic person is affected, as well as the person's awareness to a situation and towards reality in general. Dr. Hammer 16(pp165) writes that "Heart energies are responsible for the higher, conscious, intellectual-mental investigation of life including: 'awareness', 'symbol formation', and communication of ideas and feeling." Therefore, psychosis is first and foremost a disorder of the Heart-Spirit. In addition to the disorder of the Heart-Spirit, other organs and systems might be out of balance and should be treated.

Sometimes the imbalance of other organs and system is the initial disorder that indirectly causes the Heart-Spirit disorder and leads to psychosis, other times the organs and system are affected by the disorder of the Heart- Spirit and contribute to psychosis (further discussed in Psychosis's Pattern Differentiation).

Psychosis (dian Kuang) in traditional Chinese medicine

Classic traditional Chinese medicine uses the term "dian kuang" to describe what we call severe mental condition. Throughout the years this term has been translated as "schizophrenia" in some texts, as "manic depression" in others or as "calm madness and agitated madness". Rossi19 (pp125) refers to dian kuang in broader terms: "In effect, the term dian kuang is used as a blanket term for various mental illnesses of psychiatric interest that concern a loss of ability to comprehend the meaning of everyday reality and to behave in an autonomous and responsible manner" According to Xiehe Liu20 records mentioning psychiatric illness can be traced back to the very beginning of Chinese history. The word kuang (mania, psychosis with excitation) first appeared in 1100 B.C. The word dian (psychosis without excitation) first appeared between 781 and 771 B.C.

Huang P.Y suggests some translations to the traditional texts describing psychosis: dian and kuang21: Nan Jing, The Classics of Difficulties. In question 20, it reads: "When Yang is excessive, it is called kuang. When Yin is excessive, it is called dian."

In Question 59, it reads: "dian kuang diseases, how can one differentiate? When the kuang disease begins, one usually sleeps little, or is not hungry. One feels superior in virtues and intelligence. One laughs incessantly and loves to sing and dance. When the diaan disease begins, one feels sad and depressed. One stares vacantly straight ahead." The Yellow Emperor's Medicine, Book 8 Chapter 30: The Yellow Emperor: "Excellent! When the (mental) disease is serious, one discards one's clothing and runs around naked, climbing up high places, singing loudly and even not eating for several days. Why is it that these people

Table 1 Substance Yin/Yang categorization.

Yang substances Yin substances

Substances Alcohol, Tobacco, cannabisa, cocaine, Heroin, opium, morphine, cannabisa,

caffeine, amphetamines (cathinone, sleeping pills, pain relief medication,

speed), Ritalin, MDMA (a mild psychedelic mild anxiolytics — clonazepam

stimulant) LSD (psychedelic,

hallucinogenic stimulant)

General Warming, acrid, slightly bitter and Cooling effect/neutral

characteristics'3 aromatic. Enters the heart and

stimulates the spirit, dries and damages

the spleen, encourages creation of phlegm

Effects Moves blood and energy flow, arouses Calms the mind and spirit, sedative,

and stimulates, enhances physical slows down and suppresses physical

strength, opens the orifices and chemical processes

Pathology Affects yin, causes deficiencies in blood Affects yang, causing blood and energy

and yin (in the Heart) as well as stagnation as well as building up of

phlegm-heat that can harass the Spirit phlegm clouding the Spirit

a The cannabis plant includes many species with the effects varying from stimulating and hallucinogenic to plants that have a calming effect.

b However each substance should be examined separately.

can climb to the top of houses and high places when normal people cannot?"

Chi Po: "The four limbs are the extensions of the various yang. When yang is excessive, the four limbs are strong. That is why these people can climb to high places."

The Yellow Emperor: "Why does one discard one's clothing and run around naked?"

Chi Po: "Because there is excessive heat in the body, one discards one's clothing and runs around naked."

Further discussion on the manuscripts can be found in the introduction to Lou Pai-ts'eng's book.22

Psychosis's pattern differentiation

Chinese medicine provides us with several models to view any phenomenon or pathologies. Existing models include yin/yang, heaven/earth/man, five elements, six excesses, eight principles and syndrome differentiation. Each one can explain psychosis and give us different methods of treatment. This article will focus on 3 models: yin/yang, five elements and syndrome differentiation.

Yin—Yang differentiation

The following table summarizes the concept of yin psychosis and yang psychosis as written in the classics texts (Table 2).

Yin type psychosis should be treated with yang treatments. For example: using moxa, using points on the yang meridians or with yang action. Yang type psychosis should be treated with yin treatments: sedative and calming.

Five elements and emotions

According to traditional Chinese medicine, emotions can cause internal disease and when extreme or prolong, they can injure the spirit and eventually lead to psychosis: "Therefore, fright, nervousness, thought and contemplation may cause harm to the spirit; an abundance of

enduring fear may spring from the hart spirit. Life is in danger, just as soon as excess of sadness causes harm to the internal organs which, in turn, leads to an exhaustion of energy. A dispersion of the spirit and even its entire consumption may follow from an excess of joy. An excess of worry may cause a blockage in the flow of energy. Frenzy may cause dizziness and loss of self-control. Fear may cause a waste of the spirit and its dispersion. "Ling Shu Chapter 8.19 (pp 726)

Emotions belong to the elements and are stored in the Zang organs. As the movement of qi in the element so the emotion has a movement of qi "... Anger will force energy to move upward; joy will cause energy to relax; grief will cause energy to disperse; fear will cause energy to move downward; ... contemplation will cause energy to coagulate ..." Su Wen Chapter 39.19(pp 248)

My professional experience could lead me to the conclusion that one can use this observation of the movement of qi and categorize the behavior and emotions of the psychotic person according to the five elements model. One obvious example is one where signs of anger and rage in a psychotic person might mean that, beside the disorder in the Heart-Spirit, the Wood element (liver and gallbladder) is out of balance. This might be affecting the disorder of the Heart-Spirit and should be addressed during treatment. A question arise when we are facing more complex emotions, for example how to classify a psychotic person that shows caring towards his surroundings, or one that express shame and guilt?

Table 3 provides an example of these categories as an extension of the energy movement of each element.

Different diagnosis according to pattern

Listed below are the Different Diagnoses of diaan kua ng based on Flaws and Lake.23

A. Stagnated liver-qi transforming fire pattern

Main symptoms: Emotional tension, agitation, irritability, easy anger, bouts of explosive, possible violent anger; tongue: red or red tongue edges, or swollen tongue edges with thin yellow possibly slightly dry coating; pulse: wiry, rapid.

Acupuncture treatment: Xingjian (LR2), Xiaxi (GB43), Laogong (PC8), Daling (PC7), Jianshi (PC5), Dazhui (GV14)

B. Phlegm fire harassing above pattern

Main symptoms: Impetuosity, rashness and impatience, breaking things, injuring other people, cursing and foul speech, an angry look in the eyes, red complexion, reddened eyes, bound, constipated stool; tongue: red with slimy, yellow coating; pulse: wiry, large, slippery and rapid.

Acupuncture treatment: Dazhui (GV14), Renzhong (GV26), Neiguan (PC6), Laogong (PC8), Fenglong (ST40), Taichong (LR3)

C. Heat in yangming pattern

Main symptoms: Mania, agitation, deranged speech, red complexion, a tendency to strip off one's clothes, no eating

Table 2 Yin/Yang psychosis.

Yin psychosis (dian) Yang psychosis (kuang)

Patients may experience/ Patients may experience/

express/feel: express/feel:

- withdrawn behavior - Nervous and angry

- feeling they are - Feeling they are

persecuted persecuted that might

lead to violent behavior

- Fear and anxiety - Much love and happiness

- Thought loops; the mind - Mania

is preoccupied causing

communication difficulties

-Difficulty to speak up and - Shouting, singing, sobbing.

produce sound

- Inner motion - trembling - Expansive movement,

and restlessness, may be taking up space

also unobtrusive

- Feeling cold - Feeling hot

Slow speech and thought, Rapid, incessant, excessive

usually introverted and speech and thought

withdrawn

Table 3 Five elements psychosis.

Element qi zang emotion Emotions extension

Wood Rise up Liver Anger Aggressive

Mania with

irritable mood

Fire Becoming Heart Elation Joy

loose Grandiose

Mania with elevate

or expansive mood

Earth Knotted Spleen Obsessive Caring

thoughts Constant try

to please

Metal Disappears Lung Sadness Introverted and

unhappy

Scruffy and neglected

Obsessive compulsive

disorder

Water Descends Kidney Fear Paranoid

Anxious

Shame and guilt

can be place here

for days, constipation with dry bound stool, scanty reddish urine; tongue: red with dry yellow coating; pulse: deep, rapid, forceful.

Acupuncture treatment: Hegu (LR4), Quchi (LR11), Neiting (ST44), Zhigou (TE6), Dazhui (GV14), Laogong (PC8)

D. Stagnant heat pattern

Main symptoms: emotional lability, agitation, muttering to oneself, delusional thinking, auditory and visual hallucination, dark complexion with dull expression, piercing headache; tongue: dark red with static macule or spots, possible engorged, tortoise sublingual veins and/or dry yellow coating; pulse: wiry, rapid possibly skipping pulse.

Acupuncture treatment: Xuehai (SP10), Sanyinjiao (SP6), Hegu (LI4), Quchi (LI11), Tianshu (ST25), Dazhui (GV14)

E. Pattern of combined phlegm and qi

Main symptoms: Paranoia, lots of worries, nonsensical speech, muttering to oneself, tendency to sighing, no thought for food or drink, tendency to profuse phlegm; tongue: thin coating; pulse: wiry, slippery.

Acupuncture treatment: Renzhong (GV26), Neiguan (PC6), Shenmen (HT7), Zhongwan (CV12), Zusanli (ST36), Xingjian (LV2), Fenglong (ST40)

F. Phlegm dampness obstructing internally pattern

Main symptoms: Inattentiveness, difficulty thinking, slow movements, lack of strength, cowering, solitariness, possible visual and auditory hallucination, torpid food intake, insomnia; tongue: fat, swollen, teeth marks on edges, slimy white coating; pulse: slippery or deep relaxed.

Acupuncture treatment: Neiguan (PC6), Shenmen (HT7), Zhusanli (ST36), Fenglong (ST40), Pishu (BL20), Weishu (BL21).

G. Heart spleen dual vacuity pattern

Main symptoms: Excessive thinking, worry and anxiety, dreaming of ghost, confusion, palpitations, easily frightened, a predilection to sorrow and desire to cry, difficulty thinking, sallow yellow or pale complexion, reduced intake of food; tongue: pale typically enlarged; pulse: fine, forceless.

Acupuncture treatment: Xinshu (BL15), Pishu (BL20), Neiguan (PC6), Shenmen (HT7), Zusanli (ST36)

H. Blood stasis obstructing internally pattern

Main symptoms: Emotional lability, irritability, muttering to oneself, torpid spirit, paranoia, delusional thinking, auditory and visual hallucinations, dark complexion with dull expression, piercing lancinating headache; tongue: dark red with static macule or spots, possible engorged tortuous sublingual veins; pulse: wiry, choppy.

Acupuncture treatment: Zusanli (ST36), Xuehai (SP10), Geshu (BL17), Shenmen (HT7)

Part Three: Psychotic patient — method of treatment

When treating psychotic patients, I divide the therapy into two phases: Phase I: Acute. Provide emergent care to the psychotic patient. Phase II: When the patient is no longer in a psychotic state, it is time to start treating the root, initial cause of the substance abuse, the addiction and the onset of substance induced-psychosis.

Phase I: Acute treatment for psychotic patients

This phase usually takes no longer than a few weeks. According to the DSM-5, when full mental disorder persisted for a substantial period of time (e.g., at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication one should consider an independent mental disorder such as schizophrenia, bipolar disorder or any other non-substance-induced disorder.1 During the first acute therapeutic phase there is no significance whether other mental disorders exist. However, for the second phase and when treating the root, it is fundamental to determine whether or not a mental disorder exists, as it impacts the therapeutic strategy.

When encountering psychotic patients, I believe it is important for the therapist to bear in mind that although the patients are psychotic, still, not all parts of the Spirit are psychotic and some parts are indeed incarnated in reality. Nevertheless, both psychotic and healthy parts may transform from one minute to the next or from one therapist to the other. Sometimes psychosis is out in the open and obvious (both yin psychosis and yang psychosis), while in other cases it is not. With the understanding that the world around them does not accept their inner world, the healthy parts may be able to control and conceal the psychotic thoughts, hiding them away. Sometimes introverted taciturn patients can be psychotic as well; living in a fragile reality, they may be frightened and feeling they are being persecuted.

Diagnosis

Perhaps most important and the therapist's greatest achievement is the introduction of therapy to the psychotic patient and the keeping of the therapeutic process and treatment going. Throughout the process there will be continual requirement to improvise, notwithstanding the basic requirement to keep up a fixed therapeutic structure. At times the therapist may be required to leave out certain therapeutic components, regardless how important they are to the overall process. For instance, sometimes I will be providing therapy without checking the pulses first, something I will never do with any other patient. Often, the therapist is required to "join" the patients in that same place they are in, i.e. in their psychotic world (and not try to bring them into "our sane" world), all in order to create a relationship based on trust and to encourage therapy.

Throughout the diagnostic procedure therapists should utilize all means of Chinese medicine available, acquired during their training and practice. Very often, and also due to the patient's condition, anamnesis is irrelevant. Hence, therapists are required to carefully utilize their senses e.g. sight, hearing and touch.

Over the years, I have come to realize that one of the most important tools assisting me with diagnoses is observations derived from answers to the questions: what do I feel when encountering this patient? What are my overall physical and emotional reactions and feelings towards the patient? This tool is critical when communication, pulse and body diagnosis are not possible due to the psychotic state. For instance, when a psychotic patient comes into my practice, and with his or her entry I feel intimidated, my body contracting and there is tension in my jaws; observing these feelings and reflecting on them is extremely informative, also providing information concerning the patients' type of psychosis, their inner world and which organs and elements have been affected.

Therapy

As discussed earlier, psychosis is first and foremost a disorder of the Heart-Spirit. The treatment should address this basic condition plus any other syndrome or elements that has been affected.

1. Points that influence the Heart/Spirit. For example, points on the Heart and Pericardium Channel: Shangxing (GV23), Fengfu (GV16)

2. Strengthening the earth. For example, Zusanli (ST36), Zhongwan (CV12), Xiaohai (SI8), Daling (PC7)

3. Reducing excesses techniques-blood-letting, dispersing wood/fire/well points, reducing phlegm. For example, Xingjian (LR2) disperse, Fenglong (ST40), Shaochong (HT9) disperse

4. Strengthening yin. For example, open Renmai, open Yinweimai, Zhubin (KI9), Sanyinjiao (SP6)

5. Cooling techniques. For example, Ququan (LR8)

6. Treating according to the syndrome differentiation

It is recommended to combine reducing excesses with reinforcing deficiency, utilizing more than one approach. I consider ascending and energy driving points as contraindication in treating psychosis (also in yin psychosis). Most patients I have met did not suffer from any physical problems, and were physically healthy. Perhaps on account of

their young age and maybe indicating how vulnerable they actually are; imbalance immediately affected the mental level in depth, without affecting the physical level at all. From my experience, ideally patients should undergo therapy once a day or once every other day. In cases medication has been prescribed and patients adhere to the treatment, therapy can be provided once a week.

When coming down from psychosis, about one third of the patients may experience post psychosis depression (PPD).24 I would like to suggest that the spirit that was soaring high (look at me everyone, I am Jesus. I came to bring unconditional love the world . ) crashes into reality, and what emerges is depression. Another suggestion is that the psychosis required too much energy from both the body and spirit, to the point they are left with no energy to keep them going. In such cases, the syndromes that are visible are yang deficiency, lack in wood movement, lack of energy and fire in the heart.

During this interim phase, it is vital to strengthen the patients' energy however without empowering the wood and fire too much, in order not to create recurring psychosis. It is also important, at this point, to explain that this phase is part of the psychotic process and will not persist for long.

Phase II — Treating the addiction and the pain

This phase begins after the patient has come down from the psychotic state and the Spirit is incarnated. As mentioned in the Introduction ongoing substance abuse increases the chances to recurrent psychosis. Therefore, the therapists must keep in mind that if they cannot help patients break the vicious cycle: pain-substance abuse-additional pain-substances, they will not be able to help them keep away from falling back again, from recurring episodes of psychosis and thus, fail to help them lead a full life.

Based on my own experience (and of colleagues from other disciplines), I'm suggesting that throughout the entire therapy process, therapists must remember that not only that the spirit "chosen" psychosis is not random, but the specific form of psychosis is not random as well. In the exactly same way, a chain breaks where its link is weakest; the spirit, when overloaded with hardship, falls apart where it is most vulnerable. For example, a patient who suffers from a manic and paranoid psychosis has a recurring theme of having a mission to make people talk about their difficulties, to communicate with each other and to express their feelings. After recovering from the psychosis and starting verbal and family therapy, one of the main issues he was facing was the way his family handle emotions and feelings—they did not talk about difficulties and hid all theirs feeling inside. The form of psychosis and its content are therefore imperative for understanding patients energetic frameworks, where and what their weak links are, and also which "lessons" they are required to learn.

Another point to remember is the kind of substances the patient was using. As mentioned before each substance has different influence on the body and the choosing of the substance indicates the specific imbalance and where the deficiencies are. A question that should be asked is "what did you like about the substance you used?" the answers may vary, for example-some will say that it helps them to communicate (might indicate imbalance in the ministerial

fire), others say that it made them forget (might indicate about a some sort of a trauma in the past), or gave them some tranquil (might indicate excess in the nervous system).

As discussed earlier both addiction and psychosis are imbalance of the Heart. In light of that, the treatments in the second stage should always consider the state of the Heart as well as connecting Heart- Kidney and addressing the Pericardium, Triple energizer and Earth element that are part of the layer of pain that lay beneath the addiction. In some cases Wood needs to be ascended, allowing patients to express anger. In other cases, Water and self-esteem need to be strengthened, while others require setting boundaries and so forth.

I find it imperative to always bear in mind that a process of this nature takes time and has no short-cuts. It is a step-by-step process creating a relationship of trust while building, balancing and stabilizing the body's energetic mechanism.

Part Four: Case studiesf Case 1

Male. Age 20. Psychotic with aggressive behavior. He received our care after involuntary admission in a public hospital. He had a similar psychotic episode 3 years ago. Differential Diagnosis (DD) over the years is substance induce psychosis or schizophrenia spectrum's disorder.

Substance use: since age of 17, Cannabis daily, LSD, some Cocaine and mushrooms.

Psychiatric symptoms: grandiose delusions: "I can read your thoughts", "I'm getting messages from God", "I know that there will be war in the summer".

Traditional Chinese medicine symptoms: seems psychotic, confused, vibrations in hands, stiffness in upper torso and neck. When lying on bed—vibration in the legs.

Main complaints: nervous and angry.

I sense he was on the verge of explosion with a lot of inner nervousness.

Pulse: yang pulse excess and external, yin pulse empty; Gallbladder pulse full and hard. It felt as the liver pulse position invading the heart pulse.

Diagnosis: Stagnated liver-qi transforming fire pattern.

Acute stage.

Treatment principles: calming the liver and gallbladder, nourishing yin.

1st: Tianchong (GB9), Yanglingquan (GB34), Yangfu

(GB38) disperse, Ququan (LR8), Zusanli (ST36)

2nd: Tianrong (SI17) bilateral, Fengfu (GV16) disperse,

Zuqiaoyin (GB44) bleed, Ququan (LR8)

3rd: Tianyou (TE16) bilateral, Sanyinjiao (SP6) bilateral

4th: Open yinwei channel, Tiantu (CV22)

Results: the psychosis reduced. There were still signs of it but it was less extreme. Liver and gallbladder were calmed

f Along with the acupuncture treatments the patients were treated with medicine, psychologic meetings, few types of group therapy and more. In no way I'm suggesting that the acupuncture treatments improve the patients condition by itself.

down and yin was built. There was still nervousness but along with it there was an increasing ability to calm down.

Case 2

Male. Age 22. Psychosis started a year ago after meditation retreat. Anxiety episodes in childhood.

Substance intake: Cannabis for 3 years. Stopped before the meditation retreat.

Psychiatric symptoms: dull and suspicious affect; Grandiose, somatic, reference and persecutory delusions: "the Devil controls me", "my father blocked all my energy", "I can read your mind"; Somatic and auditory hallucination.

Traditional Chinese medicine symptoms: his main complaint: "I have pain in my inner organs" additional complains: headaches, insomnia, nightmares.

Pulse: all yang pulses were excess, yin absent.

Diagnosis: excess of yang and separation between yin and yang.

Acute stage.

Treatment principles: strengthen Spleen and Stomach, pacify yang.

Treatments:

1st: Zusanli (ST36), Jianshi (PC5)

2nd: Sanyinjiao (SP6)

3rd: Chengjiang (CV24) disperse

Results: decrease in hallucinations and delusions; More grounded and aware of himself.

Two Weeks later, the patient started post psychotic depression.

Treatments:

1st: Guanyuan (CV4), Qihai (CV6)

2nd: Chongyang (ST42)

Second stage-treating the root.

Treatment principles: assisting him with the anxiety episodes—nourishing Heart and strengthening Kidney; with lack of self-confidence and self-worth—Strengthening Spleen and Stomach and with his difficulties in communication—nourishing the Pericardium and strengthening the Triple energizer.

Treatments example:

Fuliu (KI7)

Zhigou (TE6), Dadu (SP2), Rangu (KI2)

Jiexi (ST41), Zusanli(ST36)

Open Du channel with point along it such as Baihui

(Du20) and Mingmen (Du4)

Results: following five months of treatments the patient no longer had symptoms of psychosis, his communication skills and ability to express his feelings were increased and his anxiety attacks were less severe.

Case 3

Male, Age 25, admitted with manic episode after a few weeks of insomnia and drug abuse. At that time he was

overloaded with music production, working as an interior designer and as a carpenter (all of which required his creativity). He had manic episode in the past and was diagnosed with bipolar disorder.

Drug intake: marihuana on a daily basis for 5 years, cocaine on a regular basis and occasional use of MDMA, Valium and crystal meth.

Psychiatric symptoms: manic episode, paranoid and grandiose delusions, unorganized thoughts, suspicious.

Traditional Chinese medicine symptoms: suffers from chronic sinusitis, mainly in the summer. Abscess on the back and on the right cheek, Desires for sweets, constipation (once every 3 days) with dry stool.

Pulse: yang—strong and flooding, bladder—slippery, liver—tight, spleen—slippery.

Tongue: red, swollen, thick and greasy yellow coating.

Diagnosis: Phlegm fire harassing above pattern.

Acute stage.

Treatment principles: expel phlegm and purge fire from the heart and liver.

Treatments examples:

Fenglong (ST40), Quepen (ST12), Pianli (LI6), Wenliu

Quanliao (SI18) disp, Yanggu (SI5) disp, Shaochong (HT9)

bleed, Cuanzhu (BL2)

Fenglong (ST40), Jimen (SP11), Daheng (SP15), Tongli

Formula: Chinese Thorowax Root (Bupleuri Radix) 9 g, Milkvetch Root (Scutellariae Radix) 9 g, Golden Thread (Coptidis Rhizoma) 9 g, Pinellia Tuber (Pinelliae Rhizoma preparatum) 9 g, Rhubarb (Rhei Radix et Rhizoma) 15 g, Sodium Sulfate (Natrii Sulfas) 18 g, Turmeric Root Tuber (Curcumae Radix) 9g

Result: after 2 months, the manic episode with the delusions was gone. The speed of speech was settled and phlegm was reduced. Abscess was significantly reduced.

Second stage—treating the root.

The patient's background: when he was young, his father was diagnosed with bipolar disorder, the father declared bankrupt and tried to commit suicide. His parents divorced when he was 15 years old, he had a traumatic car accident at age 13, one of his best friends died in the army and he himself had some rough experience during his army service. All those events caused an emotional trauma that eventually led to the intensive drug abuse.

Treatment principles:

As part of the recovery from his emotional traumas and to avoid relapse of drug abuse, this patient needed to find his middle ground. Meaning—he needed to avoid any unnecessary burden on his Spirit, keep his routine and balance his life. On the other hand he needed to keep cultivating his creativity (as an artist) in order to fulfill himself and avoid depression.

Balancing Earth (Spleen and Stomach) and Fire (Heart, Pericardium, Triple energizer): too much of the former would lead to depression; too much of the latter would lead to mania.

Results: after five months of treatments, there were no signs of phlegm in the level of the body (as abscess or sinusitis) nor the Spirit/mind. His rehabilitation plan was

settled and he managed to balance his creativity and his lifestyle.

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