Case Study: The Treatment of Anxiety in a 61 Year-old Female

I thought I'd share a case that demonstrates the multi-leved approach to treating disease that TCM offers. Here is a patient who was experiencing psycho-emotional symptoms as well as physical symptoms, both stemming from the same root cause(s). It's a bit long, and there's a lot of Chinese medicine jargon, but I think it's definitely an interesting case.  

History

Chief Complaint: The patient is a 61 year-old female with a chief complaint of anxiety.

History of Present Illness (HPI): 

The patient has had chronic anxiety and cannot identify an exact time of onset or direct cause. She has experienced an acute exacerbation of symptoms in the last couple years due to taking on the role of caretaker for her mother, who suffers from Alzheimer's disease. Her main symptoms are stress and worry, nervous energy, and insomnia, as well as hot flashes in extreme instances. She also experiences gastrointestinal symptoms for several hours following meals; these symptoms include distention, borborygmus, sluggish and loose bowels, and occasionally describes her digestive tract as feeling “raw and inflamed.” The digestive symptoms both become worse during times of increased anxiety and aggravate her anxiety. Consuming dairy makes her digestive symptoms worse. She takes melatonin to help her sleep, and bikram yoga helps with her overall anxiety level. The patient has been receiving acupuncture treatments for the past 3 years with weekly treatments focusing on this chief complaint beginning 6 months ago. Upon beginning treatment for anxiety, the patient said her symptoms were severe, while recently she has indicated that they range from mild to moderate, depending on outside factors throughout the week.

Current Health Status: 

The patient is overweight, weighing 219 lbs at a height of 5'2”. She believes she has a healthy diet consisting of fresh vegetables and organic meats and does not consume junk food; her diet and eating habits are dictated by dietary needs of her husband, who has stage 3-4 kidney failure. She does not exercise regularly but tries to attend bikram yoga classes 2-3 times per week, though in the 6-8 weeks prior to the writing of this report, she has lacked the motivation to go. Her ailing mother is a significant source of stress in her life. Although diagnosed with Alzheimer's disease, her mother lives alone, and it is the patients responsibility to care for her. She frequently has to deal with issues relating to her mother's housing and neighbors.

[Partial] Review of Symptoms (ROS):

• Gastrointestinal: distention, fullness, bloating, gas, borborygmus, sluggish and loose bowels, and occasionally describes her digestive tract as feeling “raw and inflamed”
• Psychiatric: Anxiety, tendency towards depression during winter months
• Temperature: tends to run warm, hot flashes which have decreased in frequency and intensity over the last 6 months
• Sweat: sweats easily, night sweats in the summer
• Appetite: varies widely from “totally out of control” to disinterested in food
• Thirst: thirst is normal but increases water to compensate for fluid loss when practicing yoga
• Bowel movements: ranging from soft and sticky to loose
• Sleep: typically falls asleep watching TV and wakes up in the middle of the night unable to fall back asleep; requires melatonin to sleep through the night
• Menses: menopause at age 47

Assessment

TCM Disease Category: 

The patient's condition falls under the Chinese disease category 优 思 (you si), meaning “to be anxious and worried; pensive.” Bob Flaws describes the symptoms as a tendency to worry and continuous or excessive thinking. 优 shares a phonetic component with 尤 (you), meaning “a fault” or “to express discontentment against” with the addition of 人 (ren), the radical for “person.” 思 includes 心 (xin), the heart radical, implying an emotional component to its meaning. Classically, the emphasis on this condition was the tendency towards preoccupation and unnecessary contemplation rather than the frantic nature of many modern anxiety disorders.

TCM Diagnosis: 

The anxiety that this patient experiences is caused by a pattern Spleen Qi and Kidney Yin Deficiency Heat Vexing the Heart. The patient's tongue presentation indicates a deficiency of Yin and fluids with its narrow shape, lack of moisture, and thin, dry coat, and heat in the Heart is evident by the red tip. The pulse demonstrates a relative excess in the Upper Jiao in conjunction with Kidney deficiency, giving rise to heat unanchored deficiency heat. The patient's reports of hot flashes support this conclusion. The pale tongue and lack of moisture could also point to Spleen deficiency since the Spleen is the source of the creation of Qi, Blood, and Fluids. The propensity towards stress and worry, as well as the poor digestion, is also explained by Spleen deficiency, and the noted “raw and inflamed” feeling of her gastrointestinal tract points to heat in the Middle Jiao, which will be discussed later. The two sources of heat near and rising up to meet the Heart cause her anxiety.

TCM Differential Diagnosis: 

Other possible patterns for this patient include Liver Qi Stagnation/Liver-Spleen Disharmony,

Heart-Spleen Dual Deficiency, and Lung-Spleen Qi Deficiency. Liver pathology was considered given the emotional component of the symptoms, particularly the frustration that comes with caring for her mother, and, indeed, flare-ups may be due to acute Liver Qi stagnation. However, Liver conditions were ruled out as her primary pattern due to the lack of a bowstring pulse, red sides of the tongue, ribside pain, and tendency towards anger or aggression. Dual deficiencies of the Heart and Spleen were not considered because the patient does not exhibit shortness of breath, disinclination to talk3, lassitude of the spirit, heart palpitations, or pale face, lips, and nails. Similarly Lung deficiency was ruled out due to a lack of fatigue, sorrow, lassitude of the spirit, desire to cry, chest oppression, shortness of breath, feeble voice, and cough. 

Etiology and Pathomechanisms: 

The patient's condition of Spleen Qi and Kidney Yin Deficiency Heat Vexing the Heart comes

from a combination of internal emotional and constitutional factors. According to the Nei Jing (Inner Classic), thinking causes Qi to bind, inhibiting its Qi mechanism and obstructing its upbearing of the clear. Worry and stress also weigh heavily on the Spleen, taxing its Qi and limiting its efficiency in generating Qi, Blood, and Fluids. A weakened Spleen is also less able to perform its function of transmitting Qi and radiating heat property. According to Ikeda Masakazu4, the Spleen and Stomach produce Yang Qi, which is normally radiated to the skin's surface to be discharged up and out of the body. When the Qi and Fluids of the Spleen are deficient, however, there is not enough energy for Yang Qi to be completely expelled from the body, and so there is a build up of heat in the Middle Jiao. This heat tends to linger in the Yang Ming organs and channels, accounting for the patient's digestive problems and occasional rash around the knees and elbows. A constitutional deficiency of Kidney Yin due to the patient's age creates a relative excess of Yang, which rises up to the chest and face in the form of heat. This rising up of heat causes her to experience hot flashes and

combines with the heat present in the Middle Jiao to enter the chest and vex the Heart. Because the 神 (shen), or spirit, is housed in the Heart, it becomes agitated by the heat, resulting in disquiet. The patient thus experiences anxiety, additional stress and worry, nervous energy, and insomnia.

Biomedical Differential Diagnosis:

As with most psycho-emotional disorders, anxiety is difficult to classify, and a working clinical diagnosis is often determined. The patient meets several of the criteria for generalized anxiety disorder as outlined by the 4^th edition of the Diagnostic and Statistical Manual of Mental Disorders, including excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, difficulty controlling the worry, anxiety and worry that is accompanied by at least three additional symptoms,¹ and the focus of the anxiety and worry not being confined to the features of another Axis I disorder or post-traumatic stress disorder. It is difficult to determine if the condition would be pervasive and continuous in the absence of identifiable stressors. Given her role in caring for her mother, who is an Alzheimer's patient, and assisting her husband, who has numerous health issues as well, such stressors are always present. From a biomedical standpoint, her condition might not even be considered pathological considering these factors. She has not reported feeling of panic or incidences of panic attacks, so a panic disorder is unlikely. Her tendency towards preoccupation and intrusive thoughts could indicate obsessive compulsive disorder; however, she does not exhibit signs of compulsive behavior. A type of depressive mood disorder may be an appropriate clinical diagnosis; the patient reported feeling depressed and unmotivated during the winter months in addition to her general sense of anxiety and restlessness.

1The list includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep.

Treatment

TCM Treatment Principle:

The treatment principle for this patient is to tonify Spleen Qi, nourish Kidney Yin, clear heat from the Heart, and calm the Shen.

Acupuncture Treatment:

• Ren 12 – Regulate the Middle Jiao
• Ren 6 – Regulate the Middle Jiao
• ST 25 – Regulate the Middle Jiao
• SP 15 – Regulate the Middle Jiao
• ST 36 – Strongly tonify Spleen Qi
• ST 40 – Clear heat from the Yang Ming organs and channels. As the Luo point of the Stomach channel, this point is used to redirect excess Qi into the Spleen channel to tonify the Spleen organ.
• SP 6 – Nourish Yin, strengthen the Spleen
• KI 3 – Nourish Kidney Yin
• KI 2 – Clear deficiency heat from the chest and Heart (balance Fire and Water)
• HT 3 – Balance Fire and Water with KI 2, using the Fire point on the Water meridian and the Water point on the Fire meridian.
• LI 11 – Circulate heat downward, clear heat from the Yang Ming organs and channels
• UB 15 – Clear heat from the Heart, nourish the Heart, calm the Shen
• UB 44 – Nourish and calm the Shen
• SI 11 – Clear heat from the chest
• UB 18 – Nourish the Liver
• UB 20 – Nourish the Spleen
• UB 23 – Nourish the Kidney
• UB 25 – Sedate and regulate the Large Intestine
• UB 40 – Regulate the UB channel to anchor the back treatment
  
  

• ST 44, SP 2, and PC 8 were used occasionally during periods of extremely poor digestion with stronger signs on heat affecting the digestive tract.
• LU 7 and KI 6 were used occasionally to open and activate the Ren channel to circulate Yin and harmonize the upper-lower body.

Originally the patient received front-only treatments, but effectiveness increased when back-only treatments were rotated into the treatment plan every few visits. She saw the most improvement, however, from treatments which included front and back points. Front points were generally applied from top to bottom, while back points tended to follow a Shakuju pattern. With Spleen-Earth being the focal element, the following pattern was used: Fire, Earth, Water, Wood. All points were needled using a tonifying technique – in this case slight clockwise rotation until the practitioner felt a Qi sensation – with the exception of ST 44, which was sedated. SP 2 and PC 8, when used, were stimulated using contact needling. 40mm 32 gauge needles were used.

Herbal Treatment:

Da Bu Yin Wan – Great Nature Classics caplets 750 mg each, 3 caplets 2 times daily


• Shu Di Huang – Nourishes Kidney Yin
• Chao Huang Bai – Strongly sedates deficiency fire
• Su Jiu Gui Ban – Nourishes Yin and anchors Yang to control deficiency fire
• Jiu Chao Zhi Mu – Clears deficiency fire and generates fluids

This formula was chosen to address the underlying Kidney Yin deficiency as a secondary source of internal heat, whereas the acupuncture treatment focuses on Spleen Qi deficiency as the primary source of internal heat. Da Bu Yin Wan is indicated when there is Yin deficiency and upward-flaring of fire causing constant hunger, irritability, and hot flashes. According to Bensky, there is “a viscious cycle whereby exhausted yin is unable to control the up-flaring of fire, while the fire continually scorches and thereby depletes the yin [which] can only be treated by a strategy known as 'cultivating the too and clearing the source' (培其本，清其源 pei qi ben, qing qi yuan)." Thus it is necessary to both nourish the deficient Yin-essence and drain the flourishing fire. This formula was chosen over Liu Wei Di Huang Wan because of its stronger effect of descending and controlling ascendant Yang/fire from deficiency. While Zhi Bai Di Huang Wan, also focuses on draining vigorous fire from deficiencies, Da Bu Yin Wan is stronger in its effect of tonifying Yin due to its inclusion of an animal substance, Gui Ban. Because this formula traditionally includes pig spinal cord and special Pao Zhi methods of its ingredients, as well as for added convenience, the prepared form was chosen. 

Lifestyle Recommendations:

The patient was encouraged to return to her routine of practicing yoga. While the patient reported benefiting from Bikram yoga, she was advised that the hot, sweat-inducing nature of this style of yoga could be injuring her Yin and exacerbating her underlying condition. She was referred to other yoga studios where gentler styles are taught.

Patient Prognosis:

Given the external factors contributing to the patient's stress level, i.e. the health problems of her immediate family members, and considering the patient's age and its effect on her overall constitution, her symptoms are expected to be reduced to a manageable level but not fully resolved. With consistent and ongoing treatment, the patient should experience a decrease in the severity of anxiety, as well as a decrease in the frequency of episodes of anxiety. This of course depends on external factors. She should also experience calming of digestive system, with problems being maintained at a mild level.

Patient Progress:

The patient reports feeling less anxious less often and more motivated to accomplish daily tasks following weekly treatments. She also reports feeling as if her stomach is “sedated” for the week following treatments, noting an improvement from the “raw and inflamed” sensation she had previous described. Her hot flashes have completely stopped. Finally, she described noticing suppressed emotions reemerge during the course of treatment and feeling well-equipped to deal with them and let them go after treatments and discussions about her condition with the practitioner.

Conclusion:

A 61 year-old female presented with chronic anxiety characterized by stress and worry, nervous energy, and insomnia, and also complained of hot flashes and a “raw and inflamed” sensation in her gastrointestinal tract. She was diagnosed with Spleen Qi and Kidney Yin Deficiency Heat Vexing the Heart and treated with acupuncture and an herbal formula (Da Bu Yin Wan) to tonify Spleen Qi, nourish Kidney Yin, clear heat from the Heart, and calm the Shen. The patient likely has a generalized anxiety disorder. Weekly treatments have managed to improve her mood, reduce the severity and frequency of feelings of anxiety, improve her digestion, and stop her hot flashes.