Hepatic psychoneurosis (Part 1)

Preface

Urban life is full of stress, therefore, Hongkong people are susceptible to neurosis, nervousness, mental fatigue, depression and insomnia.  The basis of TCM is to balance yin and yang; it concentrates on the liver because it has the function of smoothing and regulating the flow of vital energy and blood.  Analysis of hepatogenic psychoneurosis caused by liver disease is helpful for the understanding of clinical diseases such as hepatogenic psychoneurosis, hepatogenic neurosis (including neurasthenia, disorder of thought, obsession) hepatogenic autonomic nervous system disorder and hepatic complications that lead to climacteric symptoms, postpartum depression and sub clinical hepato-encephalopathy.  Hepatic neurosis are closely related to liver diseases; when liver disease is treated with effective systemic TCM therapy, the hepatogenic psychoneurotic symptoms are also relieved and the disease may be cured at the same time.

The concept that “hepatogenic virus is the origin of many diseases” may not be accepted by many people, but the experience of our several decades of clinical practice makes us believe that this may be the truth which is worthwhile to be introduced to the community.  In the past, a great deal of professional knowledge (including medical knowledge) were monopolized and people were often unable to have the knowledge that they should have and no matter from whom they received treatment, whether TCM or WM, the treatment they could have was symptomatic, that is, “treat the head when the pain is in the head.”  In fact, quite a number of previous issues written by specialists had contents about “liver disease”; they introduced that “hepatophilic virus” could damage many systems of the human body causing functional impairment and consequent development of different disease in which chronic hepatitis with psychoneurotic symptoms occupied not a small amount.

This article introduces this kind of hepatitis with “psychoneurotic” symptoms to people for the understanding of the relation between “psychoneurotic” symptoms and acute or chronic hepatitis.  If the patients know that the psychoneurotic symptoms originate from “chronic hepatitis”, they would naturally “seek for the fundamental” in treatment.  If one goes “to treat the liver” from the fundamental, probably clinical cure can be attained.

According to the physiologic function of liver which is based on TCM principle, it is not difficult to understand the affection of liver disease on human psychoneurologic system.  From the TCM viewpoint in reorganization of disease, the disorder of zang and fu organs is closely related to the symptoms of mentality.  In general, the pathogenesis of chronic liver disease, affected by pestilential evil, may lead to the production of heart fire, liver fire, abundance of lung fire and flaring up of large intestine heat.  When hepatic storage of blood is impaired, heart disease is produced, and the “storage of spirit in heart” is frustrated; the result is the appearance of symptoms like palpitation, insomnia, dreamfulness, endless crying or laughing, delirium or idleness, sleepiness, indifference, pain or heaviness over pericardial region, face and nails showing pale or purplish color, in severe cases, coma may be the consequence.

In addition, if stagnation of liver qi and uprising of liver yang occur in liver disease, the following symptoms may take place: vertigo (眩暈目花), pain at top of head, distension of breasts, pain over costal region, lower abdominal pain, unsmooth mobility of joints , clonic spasm of muscle (筋攣拘急), numbness limbs (四肢痳木), impotence (急燥), irritability (易怒) and convulsions (抽搐).  If kidney water is consumed due to prolonged excessive fire of heart, liver and kidney, weakness of kidney is prone to occur and it would further lead to deficiency of yin and increase of fire.

The TCM theory acknowledges that kidney has the function of concentration and remembrance and inability to concentrate the mind and loss of memory are common symptoms in hypofunction of the kidney.  Kidney is responsible for memory, fear and fright.  Fear is conscious and is ordinarily called timidness, being in a particular mental state fearful of something; while fright is unconscious and is a mental state caused by the sudden occurrences of something.  Although fear and fright both belong to kidney, but they are also closely related to heart which stores spirit and to liver which stores blood.  Therefore, when there is deficiency of yinand abundance of fire and uprising of liver yang, aysphoria with feverish sensation occurs in chest, palms and soles, the face and ear are red, the lips, tongue and throat are dry, the patient feels thirsty and has to drink nocturnally, the oral taste is bitter and the urine yellowish, the tongue coating thick and dark in color, the tongue proper scarlet red with pricks and ecchymoses, pigmentation appears on the face, back of hand, forearm and abdominal wall (the common sayings are freckle, senile plague, liver plague).  In severe cases, there may be anarsaca, difficult mobility, hypertension, frequent nocturia and wakefulness.

In fact, the functions of heart, liver and kidney are closely related so that when the body is invaded by pestilential evil (hepatophilic virus), the functions of zang and fu organs can affect one another and it is not surprising that various psychoneurotic symptoms occur.  It is unfortunate that modern medicine “separates apart” the wholism concept of disease and goes after only the micro-pathological changes but neglects the TCM “concept of wholism”.  Therefore, the patient loses his right “to be treated from the fundamental” and medical research might be easily directed to the wrong path.

TCM concept acknowledges that liver is “the location of spirit, the store of blood, the origin of tendon”.  The chief physiologic functions of liver are regulation of the flow of vital energy and storage of blood.  “Su Wen” (“Plain Questions” (《素問》) had pointed out :”Liver is an organ of the character of a general who does the planning and thinking”; “Liver is the fundamental of regulation and the location of spirit”.  Therefore, besides regulation of vital energy and promotion of the digestive function of spleen and stomache, the liver can regulate emotion.

If the smoothing and regulating function of liver is normal, vital energy is smooth, qi and blood are in harmony and the individual is in high spirits.  If the smoothing and regulating function is impaired, the liver qiis stagnated, emotion is depressed, and the individual is susceptible to irritation.  Sometimes, the flow of vital energy in liver is excessive, yang qi flares up, emotion is easily irritated and the individual is susceptible to anger.  Therefore, “Su Wen” stated: “In the liver disease patient, both hypochondria are painful; the pain spreads to the lower abdomen and the individual becomes angry easily”.

Liver stores blood; it also regulates blood.  If the function of blood storage in liver is normal, the spirit has its house; if the mental regulatory function of heart is normal, there is a feeling of high spirits, the hearing is clear, the thinking is nimble and the response is quick.  If the liver blood is insufficient and the blood in the heart is consumed, the spirit can not dwell in the house, so that the individual is often wakened up by horrible dreams, can not sleep well, and has sleep-walking, nightmare and delusions.  Therefore, when there is liver disease, its function of storage of blood is impaired, not only deficiency of blood or hemorrhage is induced, but also the qi of the heart is insufficient, blood is consumed, the blood vessels are not patient and the blood flow is not smooth,  These factors affect the heart to hold the spirit and when this function is abnormal, (i.e. the physiologic function of the human brain such as mentality, consciousness, thought), there will be insomnia, dreamfulness, mental instability, delirium or sluggish response, amnesia, listlessness or even coma.  At the same time, pathological changes due to insufficient blood supply may be induced, such as insufficient qi and blood in liver, weakness of tendons and muscles and unsmooth mobility due to insufficient nutrition.  If liveryin is insufficient, the patient may show tremor and numbness of limbs and unsmooth extension and flexion of the extremities.

Very close relation between liver disease and psychoneurotic disease

The relation between “liver disease” and “psychoneurotic disease” is very close.  In the present state of medical research, although investigations show that liver disease can induce simultaneously or secondary damage of the nervous system and psychotic symptoms, so far, no definite and unanimous classification has been advanced.  In fact, when there is acute infection of the human body by hepatophilic virus, the patient may also have the chance to be attacked by hepatic encephalopathy, hepatic coma, hepatic neurosis, brain edema or even meningitis, epilepsy, acute transverse myelitis, and multiple sclerosis.  In severe cases, when multiple organs are damaged due to hepatic encephalopathy, the mortality rate may exceed 77%.  Hepatophilic virus infection causes extensive damage to many systems of the body.  Therefore, patients with this acute and serious disease should be hospitalized early and receive emergency treatment immediately.  The damage of nervous system and appearance of psychotic symptoms induced by liver disease may occur simultaneously or one after another or only one of them may appear.  But, if the liver disease is prolonged or if damage of liver function is severe, and the disease has progressed into the stage of cirrhosis, the clinical psychoneurotic symptoms gradually would become apparent and the patient would progress into hepatic coma.

In the patients who clinically have manifestations of “deficiency of blood and weakness of qi” form of TCM chronic hepatitis, not a few have psychoneurotic symptoms and often they are diagnosed as having neurosis or other psychoneurotic diseases.  In the active chronic hepatitis patients (especially common in virus or alcoholic liver diseases), about 10% may develop hepatic neurosis; their peripheral neural symptoms usually appear at the late stage of liver disease (a part may appear at early stage) and these symptoms may become the chief cause of visit to the clinic.

We provide particularly the following introduction because neurosis as a complication in the early stage of liver disease is extremely common.  The statistic of our centre shows that in 3001 cases with abnormal margin of hepatic dullness, 557 cases have manifestations of “neurasthenia”, occupying 18.6%.  In 1930 female cases, 416 have “neurasthenia”, occupying 21.6%; in 1071 male cases, only 141 have such suffering, occupying 13.2%.  It is clear that neurasthenia in females has a higher incidence than male and this may be ascribed to the physiologic function of the female body which is prone to develop “deficiency of the blood in the heart” that promotes the symptoms of “neurasthenia”:

Clinically, neurasthenia is one of the most common functional diseases of neurosis; the symptoms of this entity are numerous, their manifestations chiefly are the following:

•           Mental fatigue: difficult to concentrate, low working efficiency, memory going down, poor appetite, coldness of limbs, decrease of libido, menstrual disorder or amenorrhea.
•           Nervousness: emotional instability, restlessness, hard to restrain fury, lack of patience, quarrelling for trifles, dreamfulness; generalized soreness and pain of body, tension of neck, masticatory and temporal muscles leading to headache which is persistent, simulating the tightening of a ring; headache relived after rest or by transference of concentration.
•           Insomnia: The patient is hard to fall asleep, restless, but the more effort used in getting asleep, the more irritable the patient becomes.  In the morning, the patient feels tired and the head is heavy, he still wants to sleep very much but at the same time afraid of sleepless at night, as a vicious cycle is formed.  Some patients show awakefulness and dreamfulness.
•           Hypochondriasis: Hepatophilic virus infection causes disorder of central nervous system followed by multiple system pathological changes, such as poor digestion, nausea, vomiting, loss of appetite, defecation right after meal, alternation of diarrhea and constipation, palpitation, heaviness in the chest, excessive sputum with occasional cough, unsmooth respiration, frequency of urination, menstrual disorder, impotence and early ejaculation.  Due to lack of clinical knowledge about chronic hepatitis, the patient develops various kinds of hypochondriac ideas, becomes anxious and seeks for medical help everywhere and undergoes various unnecessary examinations and treatments.
•           Anxiety and depression: confusion and worriness, often on tenterhooks, bad mood, heavy heart, in helpless confusion, restlessness, often associated with symptoms of instability of autonomous nervous system and formation of pessimistic emotions.

Yang (code number 2011) female, age 49 years.  Date of first visit: 18^th December 1999.  Her husband had history of hospitalization for acute type A hepatitis.  She complained that she had insomnia for 20 years and she had to depend on hypnotics.  She suffered at times from loin pain, tiredness and sleepiness.  She had constipation and abdominal pain since the age of 20 and often had to take cathartics to promote bowel movements.  She had hemorrhoids and hematochezia and had received hemorrhoidal operation.  She experienced repeated numbness of limbs and spasm of lower extremity muscles and also frequency of urination.  Her irregular menstruation was associated with serious dysmenorrheal and her climacteric symptoms became more apparent a year ago.  She took continuously contraceptive pills.

Physical examination: tongue red with multiple ecchymoses, anomaly of both hypochondria with protrusion of right side, hepatomegaly of 3 cm with percussion tenderness over hepatic region, prominent veins of lower extremities, large glomerulate patches of telangiectasis on right thigh.  The diagnosis was deficiency of Qi and weakness of blood associated with wetness-heat vaporization, blockage of channels and stasis of blood, deficiency of both liver and kidney.

After taking 2 parcels of TCM drugs, the liver returned to normal.  She had received 6 weeks of systemic TCM treatment, during which time she had intermittent passing of wetness-heat stools, burning sensation of anus, tenesmus and prolapse of hemorrhoids; occasionally, she had increase of sputum tinged with blood and also frequency of urination and headache.  On the continuation of TCM therapy, symptoms of neurasthenia and climacteric gradually disappeared and she stopped taking the contraceptive pills.

Published on 31st October 2002

Translated by Professor Zheng in June 2005