Should Practitioners Talk to Patients about Psychological Problems and Processes in the Context of CM Thinking and Treatment?

How Should Practitioners Talk to Patients about Psychological Problems and Processes in the Context of CM Thinking and Treatment?

Answer by Dr. Hammer

Example

Condition

A 73-year-old male patient (Mr. Q) came with symptoms of palpitations in the middle of the night and an increasing ache from certain activities, especially walking his dog and bicycling to the market. Furthermore, it occurred on his way to the market and not on the way home. He experienced no pain going up and down the stairs in his home and while playing actively with his grandchild. The ache was primarily in his left chest, shoulder, and arm, but sometimes migrated to his right shoulder and right hip, though less often. It was his conviction that he had severe heart disease.

His pulse rate was slow (52 beats/minute) and an examination of the vessels revealed ropy (twisting and standing out from the arm) and leather (hard) qualities. These are signs that the vessels are hardening, deficient of yin and that there is an obstruction to circulation that in turn would make the heart have to work harder. There was a full-overflowing wave, a sign of heat in the blood ordinarily associated with hypertension, but with no elevation in blood pressure. This is a condition associated with very long-term exercise, perhaps by participating in vigorous sport, beyond a person’s basic energy, as explained in Chinese Pulse Diagnosis: A Contemporary Approach1 and by Dr. Shen.² (This “qi wild” condition is discussed in the section on the hollow and hollow full-overflowing qualities in Chapter 8 of Chinese Pulse Diagnosis.) The drying out of the intima and media of the vessels in this case is due to lack of nourishment, rather than heat.

Exercising beyond one’s energy over a long period of time causes the yin (nourishing blood and qi) flowing in the center of the vessel to be depleted and separated from the activating yang qi at the surface of the vessel, thereby depriving the vessel walls of the nourishment needed to maintain their flexibility. Over-exercise causes gradual shrinking of yin blood—using up more than can be replaced—while the heart pumps harder to maintain circulation, causing the walls to remain distended. I have observed this combination several times in recent years, and once found it in a 60-year-old marathon runner subsequently diagnosed with Parkinson disease. I would speculate that this may involve impaired circulation to the brain related to the alterations in the blood vessels indicated by the ropy and yielding quality. However, I do not have enough clinical experience with this quality to cogently address the issue of associated syndromes.

Mr. Q was also marathon runner practicing up to 6 miles a day for most of his adult life in addition to other exercise. The leather quality on Mr. Q’s pulse and a simultaneous thick blood condition suggests that two processes were at work. One is described above involving the depletion of blood and separation of vessel from circulating blood, and the other is an excess heat in the blood for reasons to be explained.

For many years, Mr. Q has had many escalating frustrations and rage in his life that he cannot express and represses. Increasingly he feels impotent to control his own life, in which all of his lifelong plans for retirement are totally frustrated. The excess heat in his liver in order to move the stagnant qi associated with repression has entered the blood as a way of protecting the liver. However, in addition to the vessel walls being depleted of blood, they have also experienced a high degree of heat that has hardened (vulcanized) the intimae and media of the vessels.

Feedback to Patient

The object here is to relate the patient’s condition to his life experience and lifestyle. It must be clearly stated that to do so requires repeated explanations for those not familiar with the medicine until the connections are clear.

Given the symptoms of palpitations and chest ache in areas associated by the lay-person with a heart affliction, it was not a great leap from this awareness to a connection with the issue of his circulation and the condition of his vessels.

The idea that a machine that overworks, overheats, and how that heat vulcanized his vessel walls and depleted them of fluid was another easy step. That Mr. Q was this machine that was overworking through years of marathon running was also not a difficult step, despite being told for years by allopathic physicians that marathons would prevent the coronary occlusion he had just experienced.

We then came to the issue of his frustration, about which he became more voluble. Framed conceptually as a build up of heat trying to overcome his acknowledged repression, and periodically blowing off steam as with the steam in a boiler when the pressure gets to be too high, was easy to envisage. Envisaging that the escaping steam (heat) contained in his body would travel to vulnerable areas was, further, an easy step. Even easier to see from what we had already discussed was that his heart was vulnerable.

It was not a big step from here for him to see that when he experienced joy, as with his grandson, or was on his way home from the market to the “safety” of his home that he loved, that no amount of activity resulted in his ache. This brought home the association of his “heart aches” with his emotional life, especially as he was also acutely aware of his lifelong social anxiety and his relative social comfort when alone or with his family.

The “attacking” excess heat from the liver creates stagnation and chaos in the heart, interfering with the heart’s ability to circulate blood efficiently both peripherally and to the coronary arteries. From common knowledge, he had already correctly associated the chest and left arm aches with decreased coronary blood flow. The connection with his repressed emotions, the effect on his liver, and the consequences to his heart now made increasing sense to him.

This would also explain the palpitations at night. This is the time when the liver is at the height of its activity and therefore, the escaping heat has its greatest stimulating effect on his heart. It is also the time when the blood is stored in the liver and concomitantly less available to the heart. The heart must then work harder to dissipate the aimless dysfunction of heat from the liver. Since there is no exertion while asleep, the consequences are palpitations (an overworking heart) rather than an ache.