The Chang Sang Jun Renying Qikou Pulse Modality: A Theoretical Discussion and Illustrative Clinical Case Studies of Intervening Panic Attacks

                                                 Jianying Gao 1, Hongmei J. Li 2, Shusen Li 3 

1 Faculty of Health, TCM program, Kwantlen Polytechnic University, British Columbia, Canada V6X 3V8
2 Cedars-Sinai Medical Center, Los Angeles, CA, USA 90048
3 Huachang Clinic, Da Lian, Liaoning Province, China 116001

[Abstract] 

Panic disorder, as a contemporary mental and emotional disorder, lacks a systematic analysis of its etiology and pathogenesis, as well as pattern differentiation and treatment strategies in traditional Chinese medical texts. This has resulted in suboptimal clinical treatment outcomes, persistent patient anxiety, and uncontrollable avoidance behaviours. The authors of this article, under the guidance of Professor Shusen Li, learned the Chang Sang Jun Renying Qikou Pulse Modality and applied this modality to treat panic disorder, achieving excellent results. The article elaborates on Chang Sang Jun Renying Qikou Pulse Modality by examining the positioning of the Renying Qikou, the judgment of “onefold, twofold, threefold excess,” the use of Chang Sang Jun Pulse-Respiration Ratio Modality to determine “restless” (zao) pulse, the five-element attributes of the six channels, and the establishment of acupuncture prescriptions for the Chang Sang Jun Renying Qikou Pulse Modality. This method breaks through the bottleneck of the ancient pulse method’s “restless” (zao) pulse determination by accurately identifying the disease location in the hand or foot channels through the Chang Sang Jun Pulse-Respiration Ratio Modality. The article presents four cases of female patients with panic disorder, with the core pathogenesis being  “restless” (zao) pulse accompanied by the condition of heart-kidney yin deficiency and floating yang. After treatment, the frequency of panic attacks in the patients significantly decreased, and the symptoms improved greatly. The article indicates that the Chang Sang Jun Renying Qikou Pulse Modality achieves the effect of “four taels to move a thousand pounds” through pulse-based treatment protocol, providing a replicable “pulse regulation and diagnostic-treatment system ” for mental and emotional disorders.

[Keywords] Chang Sang Jun Renying Qikou Pulse Modality; Panic Disorder; Chang Sang Jun Pulse-Respiration Ratio Modality; Restless (zao) pulse

The Renying-Qikou Pulse Method is the only pulse regulation and diagnostic-treatment system explicitly articulated in the Huangdi Neijing (Yellow Emperor’s Inner Canon), and constitutes a vital component of the classical Chinese medicine pulse diagnosis tradition. In the Suwen, “Discourse on the Six Seasonal Factors and Visceral Manifestation Theory (Su Wen 9),” the correspondence of onefold excess, twofold excess, and threefold excess in Renying and Qikou pulses to specific channels is clearly delineated. The Lingshu, “Beginning and End (Ling Shu 9),” further elaborates: 

“When Renying shows onefold excess, the illness is in the Foot Shaoyang; if onefold excess becomes restless (zao), the disease lies in the Hand Shaoyang. When Renying shows twofold excess, the illness is in the Foot Taiyang; if twofold excess becomes restless, it is in the Hand Taiyang. When Renying shows threefold excess, the illness is in the Foot Yangming; if threefold excess becomes restless, it is in the Hand Yangming. When Renying is fourfold, both large and rapid, it is called ‘overflowing yang’—an external rebellion.”

“When Qikou shows onefold excess, the illness is in the Foot Jueyin; if onefold excess becomes restless, it lies in the Hand Jueyin. When Qikou shows twofold excess, the illness is in the Foot Shaoyin; if twofold excess becomes restless, it is in the Hand Shaoyin. When Qikou shows threefold excess, the illness is in the Foot Taiyin; if threefold excess becomes restless, it is in the Hand Taiyin. When Qikou is fourfold, large, and rapid, it is called ‘overflowing yin’—an internal obstruction. If the internal gate is blocked, it is beyond treatment and leads to death.”

Yet despite such profound exposition, the Huangdi Neijing leaves three critical aspects unresolved: First, the precise anatomical locations for palpating Renying and Qikou pulses are not clearly defined. Second, the diagnostic criteria for determining what constitutes “onefold excess,” “twofold excess,” or “threefold excess” remain unspecified. Third, the pulse characteristics of the elusive “restlessness” (zao) are not explicitly described. As a result, the Renying-Qikou Pulse Method has long been regarded by generations of physicians as an esoteric and impenetrable classical technique. Its intricate principles, though enshrined in canonical texts, have remained shrouded in ambiguity, impeding its systematic application in clinical practice for centuries. ^[1]

Professor Shusen Li, a direct inheritor of the Chang Sang Jun Pulse System, has devoted several decades to the rigorous study of classical Chinese medical texts. Grounded in classical doctrine and informed by a synthesis of diverse medical lineages, he established a coherent and integrative diagnostic-therapeutic framework —the Chang Sang Jun Renying Qikou Pulse Modality—rooted in the theory of Chang Sang Jun Pulse-Respiration Ratio Modality to accurately identify the “restless” (zao) pulse. The positioning of the Renying and Qikou pulses is grounded in classical theory and shaped by traditional scholarly interpretation, resulting in two main diagnostic approaches: the “upper Renying and lower Qikou” positioning and the “left Renying, right Qikou, one fen anterior to the guan position” approach. Through the of Chang Sang Jun Pulse-Respiration Ratio Modality, individuals are classified into three types: “diminished qi,” “balanced constitution,” and “restless qi (unrest qi),” thereby unravelling the millennia-old mystery of the phrase “onefold excess, twofold excess, threefold excess lead to restlessness.” ^[7]

The Chang Sang Jun Renying Qikou Pulse Modality and Chang Sang Jun Pulse-Respiration Ratio Modality embody the integration of ancient wisdom and medical techniques in this pulse diagnosis-therapeutic framework. They provide a concise yet comprehensive framework for syndrome differentiation and treatment guidance in Traditional Chinese Medicine (TCM). As a synergistic diagnostic-acupuncture system, they demonstrate both significant clinical operability and evidence-based effectiveness.

1.  Chang Sang Jun Renying Qikou Pulse Modality

1.1   Textual Examination of the “Upper Renying and Lower Qikou” Positioning

The Huangdi Neijing Tai Su: “Renying Maikou Diagnosis” records: “The Cunkou governs the internal. The term ‘kou’ (mouth) signifies the gateway through which qi flows. The Cunkou connects with the qi of the Hand Taiyin channel; thus, it is called the Cun opening. The place where qi circulates is also called the Qikou (qi opening). There is no difference between the Cunkou and the Qikou. ‘Internal’ refers to the five zang organs, which are yin. The qi of the five zang flows along the Hand Taiyin channel and manifests at the Cunkou; hence, the Cunkou governs the internal.” “The Renying governs the external. Located bilaterally at the sides of the larynx, it is the pulse of the Foot Yangming channel. This channel receives and distributes the qi of the five zang and six fu organs to nourish the human body, and thus it is called Renying. … The Renying pulse pertains to the Stomach channel of Foot Yangming, which is the leader of the six fu; it is active on the exterior, and by observing it, one may know the interior—hence it is said to govern the external.” “The Cunkou is located below, on both hands, and corresponds to yin. The Renying is located above, at the sides of the throat, and corresponds to yang.” ^[3]

Further clarification is provided in Huang Yuan Yu’s Si Sheng Xin Yuan: “Explanation of Pulse Methods – Cun and Renying Pulse Methods”: “The Qikou refers to the arterial pulse of the Hand Taiyin channel, located below the thenar eminence. The Renying refers to the arterial pulse of the Foot Yangming channel, located beside the larynx. The Taiyin distributes qi to the three yin channels, hence the Cun may be used to assess the five zang; the Yangming distributes qi to the three yang channels; hence, the Renying may be used to assess the six fu. The Taiyin is the chief of the five zang; the Yangming is the chief of the six fu.” ^[4] From these texts, it is evident that “Renying” as mentioned in the Huangdi Neijing refers to the location of the Renying (Stomach 9) point bilaterally at the pulsation of the common carotid artery, while “Cunkou” refers to the radial pulse at the Taiyuan point of the Hand Taiyin Lung channel. This clearly confirms the anatomical positioning of “Upper Renying, Lower Qikou” as referenced in classical pulse diagnosis. ^[4]

1.2  Textual Examination of the “Left Renying, Right Qikou — One Fen Anterior to the Guan Position” 

The Nanjing Chapter One says: “All twelve channels possess palpable arterial pulsations, yet diagnosis is made exclusively at the Cunkou, by which the conditions of the five zang and six fu, and the prognosis of life or death, auspiciousness or misfortune, are determined.” Since Nanjing established the diagnostic primacy of the Cun (radial) pulse, later generations of physicians have predominantly relied on palpation of the radial artery just posterior to the wrist crease as the standard site for pulse examination. ^[2]

In the Mai Jing: “The Five Zang and Six Fu, Yin-Yang, and Directional Flow Represented by the Six Pulses of Both Hands,” it is written: “One fen anterior to the Guan position is the master of human life. The left side corresponds to Renying, and the right side to Qikou.” It was Wang Shuhe who first clearly articulated that “one fen anterior to the Guan” represents the specific diagnostic position corresponding to “Left Renying and Right Qikou.” ^[6]

1.3 Determining of “Onefold Excess, Twofold Excess, and Threefold Excess”

Professor Shusen Li’s Chang Sang Jun Renying Qikou Pulse Modality inherits the theoretical foundations of the Huangdi Neijing, Nan Jing, and Mai Jing, while integrating insights from modern anatomical medicine. He proposes that the location “one fen anterior to the Guan position” corresponds anatomically to the area where the radial artery bifurcates. According to his clinical observations, the superficial and deep branches of the radial artery gradually become more palpable with age, typically becoming distinguishable in individuals over the age of 40 to 50. As for the determination of onefold excess, twofold excess, and threefold excess, Professor Li defines them as follows:

• Onefold excess refers to a pulse position that is lower than the standard Guan position;
• Twofold excess aligns horizontally with the Guan position;
• Threefold excess manifests as a pulse position higher than the Guan position.

Under normal physiological conditions, the pulse at the Renying and Qikou points remains indistinct; only when the body experiences pathological changes do these pulses become prominent.

1.4  Quantifying the “Restless” (Zao) Pulse Through Chang Sang Jun Pulse-Respiration Ratio Modality      

The “Chang Sang Jun Pulse-Respiration Ratio Modality  established by Professor Shusen Li through rigorous study of classical Chinese medical texts, represents a digitized and standardized approach to pulse diagnosis. This method forms an integral part of the Chang Sang Jun Pulse System ^{[7 ] [10]}. In Suwen: “Discourse on the Normal Qi Patterns of a Healthy Person,” it is written: “For one exhalation, the pulse moves twice; for one inhalation, the pulse also moves twice. One full breath (inhalation and exhalation) results in five pulse beats. With an occasional deep sigh, this is termed a ‘balanced person’ (ping ren). If one exhalation leads to one pulse beat and one inhalation to one pulse beat, this is called ‘diminished qi’ (shao qi). If one exhalation causes three pulse beats, and one inhalation likewise three, this is defined as ‘restless qi’ (zao). If the Chi (proximal) position feels warm to the touch, the condition is classified as a febrile disorder; if it is not warm but the pulse is slippery, the diagnosis is Wind (Feng); if the pulse is choppy, the condition is categorized as Obstruction (Bi). ^{[1 ]}  Furthermore, the Nanjing says: “With one exhalation, the pulse travels three cun; with one inhalation, it also travels three cun. One full breath moves the pulse six cun. In one day and night, a person breathes thirteen thousand five hundred times, and the pulse circulates fifty revolutions throughout the body. As water drips through the clepsydra over one hundred (ke), marking the passage of a full day and night, the Ying (nutritive) and Wei (defensive) qi each circulate twenty-five revolutions through the yang and yin channels, completing one full cycle.” ^[2]

Professor Shusen Li posits that the Huangdi Neijing and Nanjing elucidate a principal-subordinate relationship between respiration and pulse: the movement of blood and vessels is propelled by respiration. In a healthy individual, each exhalation corresponds to two pulse beats, and each inhalation likewise triggers two beats. Additionally, every 3 to 5 breaths is interspersed with a slightly prolonged pause (referred to as run yi tai xi, or “intercalated deep breath”). Therefore, one complete respiratory cycle—including this brief pause—generates approximately five pulse beats. Based on this physiological rhythm, the normal ratio of pulse to respiration is estimated to range between 4:1 and 5:1, a proportion consistent with modern biomedical parameters in which pulse rate typically falls between 60–90 beats per minute and respiratory rate between 12–20 breaths per minute. ^{[1 ]}

Accordingly, the Chang Sang Jun Pulse-Respiration Ratio Modality grounded in the principles of the Suwen: “Discourse on the Normal Qi Patterns of a Healthy Person,” utilizes modern precision timing methods to quantify this ratio. A pulse-respiration ratio (PRR) of less than 4 is classified as diminished qi (shao qi), while a ratio exceeding 5 is categorized as restless pulse  (mai zao). The ideal normative ratio is defined as 4.5. The pulse-respiration ratio is calculated by dividing the number of pulse beats per minute by the number of breaths per minute. For example, if the pulse is 80 beats per minute and respiration is 20 breaths per minute, the resulting ratio is 4—this value is termed the “pulse-respiration ratio (PRR).” ^{[7 ] [10]}

Professor Li asserts that the etymological root of the Chinese character zao (躁), which contains the radical for “foot” (足), lies in the concept of qi exuberance (气盛). He explains that when yang qi ascends to the head and then descends, and simultaneously the agitation and heat rise from the lower limbs upward, this dual directional flow results in a state of restlessness (mai zao). In such cases, yang qi floats outward excessively while yin fails to contain it; without yin’s restraining function, yang becomes hyperactive and unstable, leading to symptoms of exuberant qi and internal heat. As stated in the Suwen: “Essential and Subtle Theories of the Pulse”: “All floating pulses that are not restless are located in the yang and indicate heat; those that are restless (zao) appear in the hands. All fine and deep pulses are in the yin and suggest bone pain; those that are calm are found in the feet.” ^{[1 ]} Here, “hands” refers to the six hand channels, and “feet” to the six foot channels. The pulse-respiration ratio (PRR), as quantified through the pulse respiration method, offers a precise standard for diagnosing restless pulses (mai zao). According to Professor Li’s framework, patients classified as diminished qi (shao qi) are treated via the foot channels, while those identified with restless pulses (mai zao) are treated via the hand channels. 

The theoretical system of the Chang Sang Jun Pulse-Respiration Ratio Modality provides a digitalized and objective criterion for interpreting the concept of zao as described in the Lingshu: “Beginning and End.” This development offers significant guidance for channel-based syndrome differentiation and acupoint selection in the clinical application of the Renying-Qikou pulse method.

1.5  The Five Element Attributes of the Six Channels

In the Lingshu: “Beginning and End,” it is stated: “When the Renying pulse shows onefold excess, purge the Foot Shaoyang and tonify the Foot Jueyin—two purges and one tonification, applied once daily… When the Qikou pulse shows onefold excess, drain the Foot Jueyin and tonify the Foot Shaoyang—two tonifications and one purge, applied once daily.” Although this passage in the Huangdi Neijing clearly outlines the logic of channel differentiation, selection of channels for tonification and reduction, the number of acupoints, and the frequency of treatment, it does not explicitly define the Five Element (Wu Xing) categorization of the channels. Yet, the Five Element classification directly impacts the selection and manipulation of the Five Shu points, which are integral to tonifying or reducing techniques. ^[1]

What distinguishes the Chang Sang Jun Renying Qikou Pulse Modality is its classification of the Five Elements based on the Six Channels, rather than the more commonly used system based on the Five Zang and Six Fu organs. Professor Li argues that although channel differentiation is clearly articulated in the Neijing, when treatment involves distinctions between “hand and foot” and “upper and lower,” the Five Element categorization based on Zang-Fu organs becomes inconsistent. For example, the Hand Yangming Large Intestine channel is classified as Metal, while the Foot Yangming Stomach channel is classified as Earth—creating a mismatch between the elemental nature of the hand and foot channels. Therefore, Professor Li proposes that the Five Element attributes should be unified according to the Six Channels, wherein both Hand and Foot Yangming channels are considered as Yangming Dry Metal (Zao Jin). This approach ensures that the elemental nature remains consistent between the hand and foot channels, facilitating more effective qi regulation. This perspective represents a pioneering theoretical advancement in the field of pulse diagnosis. ^[1]

2. Panic Disorder
   2.1  Definition and Syndrome Differentiation of Panic Disorder

 Panic attacks and panic disorder are common neuropsychiatric conditions characterized by episodes of intense fear and physiological arousal. Clinically, they are marked by a subjective sense of heart palpitations, inner unrest, and in severe cases, a loss of self-control. In Traditional Chinese Medicine (TCM), this condition corresponds to various syndromes under the category of shen-zhi bing (diseases of the mind and spirit), including jing bing (fear syndrome), kong bing (terror syndrome), jing ji (palpitations due to fright), and zheng chong (fearful throbbing). The clinical presentation typically includes three components: (1) Panic Attacks: These episodes occur suddenly without a specific external threat or phobic stimulus. The patient experiences an abrupt and overwhelming surge of tension, fear, and terror, often accompanied by a sense of impending doom, fear of dying, or losing control. Physical symptoms may include muscle tension, restlessness, tremors or bodily weakness, and severe autonomic dysfunction—such as sweating, chest tightness, dyspnea or hyperventilation, tachycardia, arrhythmia, headache, dizziness, numbness, and sensory abnormalities. Some patients may also experience depersonalization or derealization. These attacks begin abruptly and typically resolve rapidly, lasting from several minutes to half an hour. Recurrence can happen unpredictably. Notably, consciousness remains intact throughout the episode. (2) Anticipatory Anxiety: Between attacks, patients often remain apprehensive, fearing another onset. This anxiety may not manifest as overt fear but rather as a generalized state of fatigue, weakness, and emotional vulnerability, which can persist for hours or even days before recovery. (3) Avoidance Behavior: Approximately 60% of patients develop persistent anxiety and preoccupation with the possibility of another attack. This leads to behavioral changes aimed at avoiding potential triggers, such as withdrawal from school or the workplace. Certain environments or situations—like being alone outside the home, waiting in lines, crossing bridges, or using public transport—may provoke anxiety due to the perceived difficulty of escaping or obtaining help should a panic attack occur. ^[8]

2.2  Etiology and Pathogenesis of Panic Attack in Traditional Chinese Medicine

Although the etiology and pathogenesis of panic disorder are multifaceted, they generally revolve around deficiency of visceral yin, dysregulation of organ qi, and insufficiency of essence and blood leading to vacuity of the brain and marrow. The primary organs involved are the heart and brain, with secondary involvement of the liver, kidney, and gallbladder. In TCM theory, the kidney governs fear, among the minds it is “fear”(kong), among the vocalization it is “groaning”(shen), thus, fear-related disorders are closely linked to the kidneys. The heart houses the shen (mind), while the kidney stores the zhi (will); a healthy mental state arises from the harmonious interaction of heart and kidney—fire and water supporting one another. The liver and kidney share a common source in jing (essence) and blood, where kidney water nourishes liver wood and prevents excessive emotional reactivity. However, when liver fire flares up, it may consume and impair kidney water, leading to kidney essence deficiency. When the kidney fails to store the zhi-will, fear arises outwardly. Clinically, the author observes that panic disorder in women of childbearing age is often accompanied by menstrual irregularities or even amenorrhea.

In Yi Xue Xin Wu (Medical Insights by Cheng Guo Ping, Qing era): “On Fright and Palpitation”, it is stated: “Jing (fright) refers to being startled; ji (palpitation) refers to the heart beating excessively; kong (fear) refers to apprehension. All three originate in the heart but involve the liver and kidney. Ji is a manifestation of heart movement, termed zheng zhong—the heart pulses restlessly and trembles. These are often caused by heart deficiency accompanied by phlegm and are treated with Ding Zhi Wan, supplemented with Banxia and Juhong. Kong-fear is governed by the kidney will (zhi), and is likewise often due to heart deficiency. As the classics say: ‘Overthinking and restlessness injure the spirit; when the spirit is harmed, fear arises uncontrollably.’ In such cases, Shi Quan Da Bu Tang is an appropriate formula.” ^[5] According to the Guideline on Integrated Chinese and Western Clinical Diagnosis and Treatment of Mental Disorders—Panic Disorder, TCM syndrome differentiation includes the following five primary patterns: Liver qi stagnation transforming into fire (肝郁化火证); Ascending water qi disturbing the heart (水气上冲证); Blood stasis obstructing the interior (瘀血内阻证); Spleen-kidney yang deficiency (脾肾阳虚证); Dual deficiency of qi and blood (气血两虚证). ^[8]

3.  Illustrative Clinical Case

The author has observed in clinical practice that, in recent years, there has been a noticeable increase in patients presenting with panic attacks. This trend appears to correlate with heightened pressures in modern life, as well as the global social, economic, and political instability following the COVID-19 pandemic. These patients typically do not have a prior history of severe emotional or psychiatric disorders such as major depressive disorder, generalized anxiety disorder, bipolar disorder, or hypochondriasis, nor have they been on long-term antipsychotic medications. Many of them report a history of panic attacks lasting over a decade, often without identifiable triggers, and frequently express confusion about the source of their fear—each case presenting with individualized panic-provoking themes.

The following case summaries focus on the comparative analysis of symptoms before and after treatment using the Chang Sang Jun Renying Qikou Pulse Modality, highlighting the characteristics of the Renying-Qikou pulse and the corresponding acupoint selections.

Case 1: Ms. J, Chinese, 43 years old, Treatment period: January 2020 to present

Ms. J is a mother of two adolescent children. She is well-supported by her family, both emotionally and financially. She reports the onset of panic symptoms without any identifiable trigger.

Primary Symptoms:
She has experienced panic disorder for over 15 years. During episodes, she suffers from palpitations, chest tightness with a sense of oppression, a choking sensation in the throat, shortness of breath, mild tremors in the body and hands, and headache with a splitting sensation. She also reports sensations of internal heat and occasional vertigo during severe attacks. Episodes are abrupt and disabling—she must stop driving immediately to seek help. She had previously attempted psychotherapy without success.

Panic Triggers:
Fear of driving over bridges and nighttime driving. At worst, she was unable to drive more than 5 kilometres.

Other Symptoms:
Scanty and delayed menstruation, with occasional amenorrhea lasting 2–3 months. She is also prone to epigastric bloating, abdominal distension, and headaches.

Pulse-respiration ratio (PRR): fluctuated between 5.2 and 6.5, indicating a restless (zao) pulse.

Renying-Qikou Pulse:
Upper Renying vs. Lower Qikou showed Qikou twofold excess with restlessness.

Primary Acupoints: 

• Tonify: Shaoze (SI1), Qiangu (SI2)
• Reduce: Shenmen (HT7)

Other Points:

• Hunmen (BL47), Po Hu (BL42)

Needles retained for 30 minutes.

Comments:
Prior to using the Chang Sang Jun Renying Qikou Pulse Modality, treatment was based on TCM pattern differentiation of heart-liver yin deficiency with deficient fire disturbing the shen. While partial improvement was noted, effects were inconsistent and relapses were frequent.

Upon applying the Chang Sang Jun Renying Qikou Pulse Modality, the therapeutic effect was nearly immediate. Panic symptoms significantly improved within two weeks. The patient was able to resume driving over bridges independently. Weekly treatments were continued for four months.

With the disappearance of chest oppression, palpitations, and anticipatory anxiety, the patient’s avoidance behaviours also resolved. She is now able to travel for extended periods (2–3 months) without treatment, with a stable condition. Currently, maintenance acupuncture is administered once per month.

Case 2: Ms. B, Caucasian, 54 years old, Treatment period: April 2022 to present

Ms. B is a successful financial advisor in the banking sector. Despite professional success, she describes her personality as somewhat indecisive. She attributes her panic symptoms to emotional neglect and subtle psychological abuse experienced in her family during childhood.

Primary Symptoms:
She has suffered from panic disorder for over 20 years, with significant worsening over the past 8 years. During attacks, she experiences palpitations, chest tightness with oppressive sensation, severe shortness of breath, and occasionally finds herself unable to speak properly,or speaks extremely slowly. Intense hand tremors occur during severe episodes. She has been receiving ongoing psychotherapy.

Panic Triggers:
Fear of interacting with new, unfamiliar, or high-profile (VIP) clients.

Other Symptoms:
Chronic insomnia and mental fatigue; heaviness and pain in the neck, shoulders, lower back, and hips; recurrent headaches; and persistent lower abdominal distention and heaviness with constipation.

Pulse-respiration ratio (PRR): fluctuated between 4.8 and 6.0, mostly indicating a restless (zao) pulse.

Renying-Qikou Pulse:
Both left Renying vs. right Qikou, and upper Renying vs. lower Qikou comparisons revealed: Renying twofold excess with restlessness 

Primary Acupoints:

• Tonify: Shaochong (HT9)
• Reduce: Houxi (SI3), Qiangu (SI2)

Secondary Points:
Yanggang (extra point), Zhishi (BL52), Zhaohai (KI6), Sanyinjiao (SP6)

Needles were retained for 30 minutes.

Comments:
Treatment was administered once weekly. After six sessions, the patient reported a marked improvement in her panic response. While she still experienced mild apprehension when meeting new clients, there were no acute attacks. Treatment was then reduced to once every 2–3 weeks. As her profession involves face-to-face consultations and detailed explanations of financial products, her most satisfying outcome was being able to speak fluently and confidently without hand tremors, even when feeling mildly anxious.

Her anticipatory anxiety significantly subsided, and she no longer experienced overwhelming dread at the thought of panic-inducing situations. She currently receives monthly acupuncture sessions focused on general health maintenance.

Case 3: Ms. A, Caucasian, 65 years old, Treatment period: July 2021 to present

Ms. A is a successful fine art appraiser known for her sharp, eccentric personality. She has practiced yoga and meditation regularly for many years.

Primary Symptoms:
She has suffered from panic disorder for over 30 years, with significant worsening over the past decade. Episodes involve intense palpitations, chest pain with a sensation of heat and sweating, nausea with a strong gag reflex, vertigo, and high-pitched tinnitus. In severe cases, she exhibits uncontrollable screaming or even hysterical behavior. She is generally resistant to psychological counseling.

Panic Triggers:
Social gatherings involving multiple people. She displays hypersensitivity to external stimuli, particularly sounds, smells, and environmental cleanliness. She is acutely sensitive to auditory stimuli—capable of detecting minute sounds in noisy environments. During panic episodes at social events, she becomes unable to communicate and must flee the setting. However, her profession often requires her to attend such gatherings, which causes significant distress. During attacks, she relies entirely on colleagues or her husband to manage the situation. Her heart rate during an episode can spike to 110–120 bpm. Despite multiple conventional cardiac and neurological assessments, no major abnormalities were found aside from mild myocardial ischemia on ECG. After age 60, she developed elevated cholesterol, but blood glucose remains within normal range.

Other Symptoms:
Chronic diarrhea, acid reflux, and insomnia.

Pulse-respiration ratio (PRR): ranged from 5.8 to 6.8, indicating marked restlessness (mai zao).

Renying-Qikou Pulse:
Both left Renying vs. right Qikou and upper Renying vs. lower Qikou revealed: Renying threefold excess with restlessness.

Primary Acupoints:

• Tonify: Yuji (LU10)
• Reduce: Erjian (LI2), Shangyang (LI1)

Secondary Points:
Ququan (LR8), Zusanli (ST36)

Needles retained for 30 minutes.

Comments:
Treatment was administered once a week or every two weeks, depending on availability, with noticeable improvement after each session. According to her husband, the patient has developed greater tolerance to environmental stimuli—particularly sounds and smells. Due to her frequent travel across North America for art appraisal work, she is unable to receive treatment regularly.

Ms. A reported that acupuncture was highly beneficial and requested a written acupuncture prescription to allow other practitioners in different locations to follow the same treatment protocol. She now aims to receive acupuncture once per month. Her anticipatory anxiety has significantly decreased, and she is able to participate in social events with more ease. Her avoidance behaviours have markedly diminished.

Case 4: Ms. H, Chinese, 49 years old, Initial consultation: June 2023; treatment began August 2023

Ms. H, a tourist from China, was hospitalized in California in June 2023 following a severe MVA. She was struck as a pedestrian and suffered the tragic loss of a family member in the same accident. She sustained a traumatic left leg amputation, severe pelvic fractures, and multiple spinal fractures. Fortunately, there was no spinal cord involvement. She underwent immediate surgery for left leg amputation.

Symptoms:
Following the accident and amputation, the patient developed severe panic attacks, experiencing intense fear and hypervigilance even while indoors. She also suffered from phantom limb pain on the amputated (left) side, described as abnormal stabbing pain in the left thigh, with a severity reaching 8–9 out of 10 during flare-ups. On the intact (right) side, she reported burning pain in the thigh, with intensity reaching 7–8 out of 10. In August 2023, acupuncture was initiated upon referral from her medical team in Cedars-Sinai Medical Center.

Panic Triggers:
The traumatic loss of a loved one and the accident itself. Daily symptoms included persistent anxiety, palpitations, severe fatigue, epigastric pain, nausea, vomiting, and insomnia—consistent with post-traumatic stress and injury sequelae.

First Session

Pulse-respiration ratio (PRR): above 5, indicating restless (zao) pulse. 

Renying-Qikou Pulse:
Qikou twofold excess with restlessness

Primary Acupoints:

• Tonify: Shaoze (SI1), Qiangu (SI2)
• Reduce: Shenmen (HT7)

Secondary Points:
Benshen (GB13), Shenting (DU24), Baihui (DU20), Taiyuan (LU9)
Dong’s extraordinary points: Linggu, Dabai

Needles retained for 30 minutes.

Second Session

Symptoms:
Significant reduction in panic symptoms. Phantom limb pain in the left amputated thigh and burning pain in the right thigh were both alleviated. The patient reported a marked improvement in sleep quality and noted this as her first restful sleep since hospitalization. Anxiety had notably diminished.

Pulse-respiration ratio (PRR): reduced to 4.75, consistent with balanced (ping ren) pulse.

Renying-Qikou Pulse:
Qikou onefold excess 

Primary Acupoints:

• Tonify: Zulinqi (GB41), Yangfu (GB38)
• Reduce: Xingjian (LR2)

Secondary Points:
Shenmen (HT7), Shenting (DU24), Baihui (DU20), Hegu (LI4), Zusanli (ST36)
Dong’s extraordinary points: Linggu, Dabai

Needles retained for 30 minutes.

Comments:
Ms. H experienced profound physical and psychological trauma. During her ICU stay, she also suffered interstitial pulmonary edema and E. coli enteritis, leading to a complex and critical clinical picture. Acupuncture was administered 2–3 times weekly during her inpatient rehabilitation period. Diagnosis and treatment were guided by the Chang Sang Jun Renying Qikou Pulse Modality, for a total of eight sessions.

By the end of this treatment course:

• Phantom limb pain completely resolved
• Panic attacks ceased
• Anxiety was significantly reduced

The patient was discharged in stable condition and transferred to a rehabilitation centre for continued recovery.

4. Summary and Discussion

        Panic attacks and panic disorder are contemporary mental and emotional disorders which lack standardized diagnostic and treatment guidelines. Moreover, literature on Traditional Chinese Medicine (TCM) approaches to panic disorder is sparse. Based on the author’s clinical observations, conventional TCM treatment principles such as those for Mei He Qi (plum pit qi), zang zao (zang restlessness), yu (depression), or kuang (mania) tend to yield suboptimal results. While symptom severity may be somewhat reduced, core symptoms often persist. This leads to sustained anticipatory anxiety, ongoing avoidance behaviour, and frequent relapses. These patients are often constitutionally hypersensitive, and other therapies—including internal herbal formulas, nutritional supplements, pharmaceuticals, or even psychotherapy—tend to have limited efficacy.

 Although the Renying-Qikou Pulse Modality appears in multiple passages of the Huangdi Neijing, it does not explicitly define how to identify a restless pulse (zao), nor does it specify the application of the Five Shu points. As a result, this classical pulse modality has long been considered esoteric and difficult to decode, with various conceptual bottlenecks preventing its practical and skillful application in clinical settings. The Chang Sang Jun Renying Qikou Pulse Modality overcomes these limitations by employing the Chang Sang Jun Pulse-Respiration Ratio Modality to precisely determine the treatment direction—whether the pathology lies in the six hand channels (heaven) or the six foot channels (earth). Moreover, by classifying the Five Elements based on the Six Channels rather than their Zang-Fu organs, the method renders this classical pulse system practical, accessible, and effective. This paper presents four clinical cases, all involving female patients, who were followed for from six months to four years. The Pulse-Respiration Ratio (PRR) values fluctuated over time, but in most cases showed a tendency toward restlessness (zao) pulse, with occasional presentations of diminished qi (shao qi). Each Renying-Qikou pulse reading varied from visit to visit; however, by tailoring the acupuncture prescription to the real-time pulse diagnosis, the practitioner was able to achieve effective pulse regulation, resulting in tranquilization of the mind, calming of the heart, and restoration of spirit.

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