Alvin Wong

Case History:

Patient: An unmarried woman, approximately 35 years of age, sought medical help from me on July 14th, 2023.

She had received psychiatric treatment outside of the United Kingdom for 10 years and had lived in the United Kingdom for 1 year. Her condition was monitored by the NHS psychiatric department. She was diagnosed with schizophrenia and melancholic depression by western medical practitioners outside of the United Kingdom and the NHS.

When she was treated outside of the United Kingdom, she was prescribed venlafaxine hydrochloride, with a dosage ranging from 37.5 mg at the beginning to 75 mg at the end of her 10th year of treatment. She has been living in the United Kingdom for more than 1 year. A NHS psychiatric specialist increased the dosage of venlafaxine hydrochloride from 75 mg to 150 mg and prescribed flupentixol 1.5 mg.

Her condition did not improve, so the NHS increased the dosage of venlafaxine hydrochloride from 150 mg to 225 mg and increased the dosage of flupentixol from 1.5 mg to 3 mg. However, her condition continued to deteriorate.

Even though she was taking high doses of psychiatric medication, she experienced the following health problems:

● Severe insomnia and lack of awareness of what she was doing

● Issues with “temporal perception”, difficulty in remembering times and dates

● Unable to comprehend short messages, emails, and articles in English, even if they were only 4-5 lines long

● Auditory hallucinations that lasted all day and increased in volume (including womens and childrens voices)

● Hallucinations and feelings that her soul had left her body and she could see her own body. She felt like she was floating in the air (commonly referred to as dissociation)

● When sleeping, she had many nightmares of bloody, violent scenes

● Terrible sleep quality

● Feeling depressed

● Sweating heavily all over her body during sleep, to the point that her clothes were wet

● No appetite

● Wet and watery feces

● Premenstrual pain so severe that she needed to take pain medication (paracetamol 2000 mg)

● Very tired with a strong desire to sleep; she could sleep for more than 13 hours at a time

When this patient sought assistance from me, she lived far from my clinic, so diagnosis and treatment were conducted via video consultation. This allowed me to observe, ask questions, and listen to her. One of the limitations of online consultation was that I could not conduct a pulse examination. To understand her condition, in addition to observing her facial expressions, I asked a lot of questions to cross-check her logic and word use in our conversation. Starting from details of her daily life, I proceeded to ask about her dreams. I also asked her to detail the locations in which her hallucinations took place.

Understanding Schizophrenia from the Western Medical Perspective

Schizophrenia is a serious mental disorder in which patients interpret reality abnormally, experiencing delusions. Schizophrenia may lead to some combination of hallucinations, delusions, and extremely disorganized or abnormal thinking, speech, and motor behaviors that impair daily functioning, and may even cause complete disability.

Causes of Schizophrenia from the Western Medical Perspective

Western pathology: Researchers believe that a combination of genetics, brain chemistry, and environment contributes to the development of the disorder.

Problems with chemicals that naturally occur in the brain, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia.

Understanding Schizophrenia from the TCM Perspective

TCM classifies schizophrenia as “hysteria” or a disorder of the spirit-mind, which is considered a kind of depressive disorder and may include the following:

1. Lily disease ［or hundred-union disease］ ［characterized by trance and mental incompetence］

2. Depression［of qi in viscera］

3. Visceral agitation

4. Plum pit qi

TCM categorizes hysteria as a type of depressive disorder. It is a disease caused by emotional disharmony and qi stagnation. Its main manifestations are depression, agitation, hypochondriac pain, irascibility, and crying, as well as pharyngeal obstruction, insomnia, and other symptoms. Clinically, it can be divided into liver qi binding depression, qi stagnation and phlegm obstruction, qi stagnation and fire obstruction, depression and devitalized essence-spirit, dual vacuity of the heart and spleen, and effulgent yin vacuity fire.

Causes of Schizophrenia from the TCM Perspective

TCM pathology: Depression is caused by 7 types of emotional discomfort and may present with a variety of symptoms. Depression may involve problems of the viscera, including the heart, spleen, liver, and gallbladder. Pathological mechanisms that cause depression can be divided into anxiety, depression, anger, and liver depression, as well as excessive worrying, spleen exhaustion, emotional overload, and heart exhaustion, among others.

Lei Jing ［The Classified Canon］proposed the medical concept of “unity of form and spirit”, as well as the academic concepts of “diseases arising as a result of depression” and “depression arising as a result of diseases”, highlighting the relationship between physiology and psychology. For example, “eye diseases can occur in people who have a bad temper This is because a bad temper reflects a tendency for the liver to be depressed. Heat is generated as a result of prolonged stagnation. Damp-heat brewing in the spleen injures the essence and qi, and covers the eyes.” This shows that extreme emotional changes can cause an imbalance of yin and yang, qi-blood disharmony, and functional disorders of the viscera and bowels.

Description of Treatment from July 14th 2023 to Present:

First, it is important to distinguish whether the patients condition of hallucinations and dissociation is a spiritual experience. If it is a spiritual experience, the patient should be referred to the relevant clergy.

Based on the results of my analysis, I was confident that she needed medical rather than spiritual assistance because depression is caused by 7 types of emotional discomfort and this patient had obvious signs of liver depression, one of which was menstrual pain. This fit the academic concept of “diseases arising as a result of depression” and “depression arising as a result of diseases”. My overall approach was to treat the imbalance of yin and yang, qi-blood disharmony, qi stagnation, phlegm-rheum, and functional disorders of the viscera and bowels. My first task was to course the liver and resolve depression.

Treatment Summary for the First Month (July 14th to Mid-August):

Clinical findings:

● Yin-yang imbalance

● Qi-blood disharmony

● Qi stagnation

● Severe liver depression

● Damp phlegm

Treatment approach:

● Course the liver and resolve depression, quiet the spirit and stabilize the mind, clear dampness

(All formulas in this clinic are pre-made concentrated powder.)

The primary formula was Free Wanderer Powder (xiāo yáo sǎn), combined with a variation of Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng).

Free Wanderer Powder (xiāo yáo sǎn), 5 g + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 6 g

The evening prescription was Spiny Jujube Decoction (suān zǎo rén tāng) combined with a variation of Free Wanderer Powder (xiāo yáo sǎn).

Spiny Jujube Decoction (suān zǎo rén tāng), 5 g + Free Wanderer Powder (xiāo yáo sǎn), 5 g

The following variations were made as appropriate:

To resolve depression and calm the mind when the heart spirit is disquieted, add 1.5 g of silk tree flower (hé huān huā)

For severe insomnia, profuse dreaming, and profuse sweating with non-interaction of the heart and the kidney, add 1.5 g of flowery knotweed stem (yè jiāo téng)

For heart vacuity with fright palpitations, forgetfulness, and insomnia, add 1.5 g of root poria (fú shén)

For fright palpitations, forgetfulness, profuse dreaming, insomnia, and to calm and settle the spirit-mind, add 2 g of Siberian polygala root (yuǎn zhì)

Outcomes after the first month of treatment:

● Nightmares reduced by half

● Auditory hallucinations reduced by half

● Sleep quality improved

● Still had anxiety/panic attacks

● Still had to take pain medication (2000 mg) for menstrual pain

Treatment Summary for the Second Month (Mid-August to Mid -September):

Note: Because the patient could not use herbal granules in her work environment due to the smell, pills were prescribed to be taken at lunch in the office. The patient continued to take powdered herbs at home in the morning and evening.

Clinical findings:

● Qi-blood disharmony

● Severe liver depression and qi stagnation

● Damp-phlegm

● Severe vacuity of yin and yang

Treatment approach:

● Course the liver and resolve depression, nourish the heart and quiet the spirit, treat heart and kidney yin depletion, supplement qi and blood

Morning: Free Wanderer Powder (xiāo yáo sǎn), 5 g + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 5 g

Lunch (2 days of herbal powder at home): Perfect Major Supplementation Decoction (shí quán dà bǔ tāng), 5 g + astragalus (huáng qí), 2 g + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 3 g

Lunch (3 days of herbal pills in the office): Perfect Major Supplementation Decoction (shí quán dà bǔ tāng) Pills, 5 pills + Eight-Gem Decoction (bā zhēn tāng) Pills, 5 pills + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 3 pills

Evening: Celestial Emperor Heart-Supplementing Elixir (tiān wáng bǔ xīn dān), 5 g + Free Wanderer Powder (xiāo yáo sǎn), 3 g + Spiny Jujube Decoction (suān zǎo rén tāng), 2 g

Modifications as needed:

To quiet the heart and spirit, tranquilize, and induce sleep, add 1 g of lily bulb (bǎi hé)

To resolve depression and quiet the spirit when the heart spirit is disquieted, add 1.5 g of silk tree flower (hé huān huā)

To dispel dampness, fortify the spleen, quiet the spirit, and disinhibit water without damaging the right qi, add 1.5 g of poria (yún líng)

To treat fright palpitations, forgetfulness, profuse dreaming, and insomnia, and quiet and settle the spirit mind, add 2 g of Siberian polygala root (yuǎn zhì)

To enter the heart and liver channels, quicken the blood and regulate menstruation, cool the blood and disperse welling-abscess, and quiet the spirit, add 1.5 g of salvia root (dān shēn)

Outcomes after the second month of treatment:

● Flupentixol was reduced from 3 mg to 1.5 mg

● Venlafaxine hydrochloride was reduced from 255 mg to 217.5 mg

● No nightmares; the content of dreams was daily life

● No hallucinations

● No auditory hallucinations

● No sweating

● No panic attacks

● Frequent feelings of anxiety

● Extreme fatigue

● Menstrual pain reduced by 50%

Treatment Summary for the Third Month (Mid-September to Mid-October):

Clinical findings:

● Moderate qi-blood disharmony

● Qi stagnation

● Moderate damp-phlegm

● Severe yang vacuity

● Moderate blood vacuity

Treatment approach:

● Course the liver and resolve depression first; nourish the heart and quiet the spirit, focus on greatly supplementing original qi, and supplement blood at the same time as supplementing qi

Morning: Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 5 g + Free Wanderer Powder (xiāo yáo sǎn), 4 g + Korean Red Ginseng (rén shēn) Powder Capsule, 1 pill

Lunch (herbal pills in the office for convenience and lack of odor): Perfect Major Supplementation Decoction (shí quán dà bǔ tāng) Pills, 4 pills + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng) Pills, 4 pills + Korean Red Ginseng (rén shēn) Powder Capsule, 1 pill

Lunch (herbal powder at home, 4 days a week): Perfect Major Supplementation Decoction (shí quán dà bǔ tāng), 5 g + Eight-Gem Decoction (bā zhēn tāng), 4 g + Korean Red Ginseng (rén shēn) Powder Capsule

Evening: Celestial Emperor Heart-Supplementing Elixir (tiān wáng bǔ xīn dān), 5 g + Free Wanderer Powder (xiāo yáo sǎn), 3 g + Spiny Jujube Decoction (suān zǎo rén tāng), 3 g

Outcomes after the third month of treatment:

● Flupentixol has been stopped for half a month

● Venlafaxine hydrochloride dosage reduced from 255 mg to 150 mg

● No hallucinations

● No auditory hallucinations

● No nightmares; dreams are about everyday life

● No more heavy sweating

● No panic attacks, but there are still feelings of increased anxiety

● Still extremely fatigued

● 50% reduction in menstrual pain

● Able to talk and communicate with colleagues and young people for 2.5 hours before feeling exhausted and dissociating

● Reduced feelings of depression and anxiety

Treatment Summary for the Fourth Month (Mid-October to Mid-November)

Clinical findings:

● Moderate to mild qi stagnation

● Moderate yang vacuity

● Mild blood vacuity

● Moderate yin vacuity

● Insufficiency of kidney water

● Lung dryness

Treatment approach:

● Course the liver and resolve depression first; focus on greatly supplementing original qi, and supplement blood at the same time as supplementing qi; supplement yin.

Morning: Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng), 4 g + Free Wanderer Powder (xiāo yáo sǎn), 4 g + acorus root (shí chāng pú), 1 g + magnolia flower (xīn yí huā), 1 g.

Lunch (herbal pills in the office for convenience and lack of odor): Six-Ingredient Rehmannia Decoction (liù wèi dì huáng tāng), 8 pills + Bupleurum Decoction Plus Dragon Bone and Oyster Shell (chái hú lóng gǔ mǔ lì tāng) Pills, 4 pills + Korean Red Ginseng (rén shēn) Powder Capsule, 1 pill.

Lunch (herbal powder at home, 4 days a week): Free Wanderer Powder (xiāo yáo sǎn), 4 g + Six-Ingredient Rehmannia Decoction (liù wèi dì huáng tāng), 4 g + Siberian polygala root (yuǎn zhì), 1 g + adenophora/glehnia root (shā shēn), 1 g + Solomon’s seal root (yù zhú), 1 g.

Evening: Celestial Emperor Heart-Supplementing Elixir (tiān wáng bǔ xīn dān), 3 g + Free Wanderer Powder (xiāo yáo sǎn), 3 g + Spiny Jujube Decoction (suān zǎo rén tāng), 3 g + Siberian polygala root (yuǎn zhì), 1 g + lily bulb (bǎi hé), 1 g + silk tree flower (hé huān huā), 1 g + ophiopogon root (mài mén dōng), 1 g.