08 The relation of liver disease with “epression” and “postpartum depression” (One of the common symptoms of “deficiency of blood and weakness of ”

Preface

According to data from Health Bureau of Hong Kong, patients suffering from depression have increased in the past three years, from 9,700 more persons in 1999-2000 to over 13,700 in the previous years and the majorities are females, between 40-60 years of age, accounting for 30% of new cases in each year.  The statistics of the Hospital Authority showed that patients with depression during the year 2001-2002 had increased 41%.  This is an indication of the degree of popularity of the disease.  Recently, there were several episodes occurring one after another, of committing suicide through jumping from a building and it was reported that these individuals were all sufferers of postpartum depression.  This article attempts to elucidate the cause of depression and postpartum depression from the viewpoint of TCM and to reveal the disease manifestation of postpartum depression on the basis of chronic hepatic disease.

According to TCM, depression is an extremely common clinical neural and psychotic condition induced by stagnation of liver qi .  It was mentioned that liver disease can produce many neurasthenia symptoms, and chronic hepatitis can cause clinical damage of many systems, so that these patients may suffer from symptoms of various systems in different stages of disease.  Modern medicine promotes the development of anatomico-pathalogy and cytopathology and pays attention especially to research and diagnosis of pathologic changes of visceral organs, trying in all ways to find out the “focus” and substantiating continuously the methods of diagnosis.  Diagnostics has shown radical changes and diagnostic means and accessory instruments have increased greatly, but there is a tendency of things to fall into another extremity and it seems now that physical examination of patients has changed to merely checking up of laboratory examination results.  Therefore, the traditional “diagnosis by syndrome differentiation” and ‘treating the fundamental” therapeutic measures are often neglected and severe neural and psychotic symptoms may be simply diagnosed as psychosis and treated as such without a time limit.

Anti-depression treatment can control illusion and emotional instability, but prolonged intake of psychotic drugs may induce side effects like stiffness of muscles, tremor, inability to sit quietly and slowness of motion.  It can also induce sleepiness, edema, salivation, vertigo, difficulty in urination and defecation, palpitation and muscle spasm.  Whether long term anti-depression treatment an ideal therapy or not is a matter of individual consideration.  But if these patients are on the base of chronic liver disease, systemic TCM therapy is still a method of choice.

Chronic liver disease patients susceptible to postpartum depression

Obstetricians and gynecologists point out that emotional fluctuation after delivery is due to the affect of hormonal changes in women who have to endure also the stress of looking after their babies, so that three months postpartum is the “high risk period” of postpartum depression.  In the early stage, the symptoms may appear as early as 3 – 5 days after delivery, including moodiness, liable to crying, insomnia and restlessness.  If the condition has changed to postpartum depression, the patient experiences fatigue, insomnia, loss of appetite, anxiety and frightfulness; in severe cases, there may be auditory hallucination, idea of committing suicide and of killing the baby.

Delivery is in fact the time of induction of the relapse of hepatophilic virus disease, because during pregnancy the liver has a greater burden, so that nutrition may be insufficient and endocrine changes often become the inducing factor of hepatic psychoneurotic disease.  Therefore, women with chronic hepatitis are prone to have psychoneurotic symptoms of postpartum depression after delivery.  Among all kinds of depressive states, postpartum depression is the one with the closest relation to hepatophilic virus infection.  Clinically, it is common to see female chronic hepatitis patients, who have obtained clinical cure after systemic TCM therapy, experience relapse of hepatomgaly following pregnancy and delivery and require a repeated systemic treatment of TCM drugs.

Traditional Chinese Medicine possesses exquisite knowledge on postpartum depression

From the TCM viewpoint on etiology, it is not difficult to find that TCM has accumulated meticulous observation and therapeutic experience in female postpartum neural and psychotic symptoms.  For example:

l          Postpartum jaundice: postpartum deficiency of blood and stagnation of qi, jaundice of skin of body, eyes face, fatigue of limbs.

l          Postpartum hypochondriac pain: postpartum damage of liver, deficiency of blood and stagnation of qi; the liver governs tendons which spread over the hypochondria so that there is distensive pain over the chest and hypochondriac intercostal spaces.

l          Postpartum panic: due to postpartum weariness, fright and tiredness, excessive loss of blood, weakness of heart qi with mental instability, causing the heart to be kept in a state of agitation and frightening, the patient showing mental disturbance, fixation of the eyes or talking nonsense.

l          Postpartum insomnia: postpartum excessive loss of blood, deprivation of nourishment to the mind, the patient therefore not able to sleep well, appearing anxious, perspiring or having flush of face and feeling thirsty.

l          Postpartum absent-minded: after delivery, heart blood being insufficient, disorder of nutrition leading to mental instability, staring eyes without expression and postpartum edema.

l          Postpartum restlessness of deficiency type: postpartum injury of qi and blood, flaring up of asthenic fire or rushing up of qi and blood, restlessness of heart, unsmooth flow of qi, anger blasting out without reason, frequent occurrence of restlessness, vomiting, vexation, asphyxiating pain in the chest.

l          Postpartum mania: deficiency of blood after delivery, the heart devoid of nutrition, fever associated with unsmooth lochial discharge, talking wildly, inability to recognize people, face greenish and lips pale, limbs cold or keeping quiet without a word or widely opened eyes staring straight forward.

At the critical periods of “pregnancy”, delivery” and “postpartum”, woman with chronic hepatitis may suffer from damage of liver function due to “deficiency of blood” or overload strain of the body.  They are prone to develop “depression” and its related symptoms and postpartum depression is the most common type of the disease.  It may finally cause death of mother and baby.  Therefore, attention should be paid keenly by family members of the patient and systemic TCM therapy should be instituted in time for prevention of further development of the disease.  Chronic hepatitis female patients in the postpartum period should be routinely examined for percussion dullness of the hepatic region and “liver disease” should be treated if necessary.

With the pass of time, liver disease patients who have not given systemic TCM therapy inevitably go into the climacteric stage, at which time sexual hormones decrease, disturbance of autonomic system intervenes.  Consequently, there is the occurrence of climacteric syndrome and perhaps the following “senile dementia” (老年性痴呆).  In fact, the patient’s psychoneurotic symptoms are the result of brain and neural tissue damage following hepatophilic virus infection and clinically they show psychoneurotic symptoms of various degrees.

Virus infection concerns health in a life time

When hepatophilic virus infection occurs in the intrauterine fetus or during infancy, it affects the victim throughout life.  In one’s life time, from birth, growing up and mature, old age and death, no period is not related to the effect of hepatophilic virus infection in the body.  The day will come when people recognize that the methods of treating “diseases” are in fact chiefly the clinical therapeutic measures of “prevention and systemic treatment of hepatophilic virus infection, prevention of liver function damage and treating in time of various complications of liver disease.

The pathological changes of the nervous system caused by hepatophilic virus inflection can be divided into acute and chronic.  In chronic liver disease patients, the concentration of “antigen-antibody complex” varies with the pass of time and its affect on brain and nervous tissue results in edema, degeneration, thinning of cerebral cortex, disappearance of neurons and nerve fibers or even patchy necrosis of deep layer of cortex.  Due to damage of auto-immune function, the patient’s detoxification power of liver becomes abnormal, vitamin B complex is deficient and together with the defect of enzyme leading to the blockage of the metabolism, so that some toxic substances can pass into systemic circulation and interfere with cerebral function and nerve impulse activity.  This is the fundamental cause of human psychoneurotic disease.

In the life time of an individual, besides external factors (e.g. alcohol addiction, drug taking, infection, medical drugs) interfering with liver function, in certain periods of life, there may exist some factors which can induce “hepatic encephalopathy” (肝性腦病) : the most conspicuous is the adolescent period, pregnancy, postpartum, climacteric and old age.  In these conditions, the effect of hepatophilic virus forms the base of liver function disturbance.  Different inducing factors (e.g. loss of blood, endocrine disorder etc.) affect the body immunologic power in different manners, but invariably the end result is damage of the brain nervous tissues with significant clinical symptoms of hepatic cerebral-neural disease.

If children with chronic liver disease go into the adolescent period, their development would be frustrated by endocrine disorder, malnutrition and metabolic disturbance following impairment of liver function.  The growth of the child is slow or there is anomaly of skeletal development (hepatogenic malnutrition and underdevelopment or hepatic osteal malnutrition) or secondary obesity.  A small number of the male sick children have a feminine type of breast development.  Their external genitalia and testicles are atrophic, their body hair scarce.  Some girls may develop a lean and high stature due to disorder of sexual hormones; their limbs are long, hairy and their secondary sexual characteristics underdeveloped.  These teen age adolescents are prone to develop “disorder of thought”.

Disorder of thought

Recently some scholars pointed out that disorder of thought is due to cerebral changes from virus infection and the inducing factor is stress and environmental changes.  This disease is an early type of abnormal psychotic condition and an extremely small part of the patients have tendency to violence.  These patients, often teenage, whose thinking and talking are in a mess, may manifest soliloquy, present a kind of through, passion and sensation away from reality and may have paranoia of being persecuted.  If not treated early, it may develop into the severer types of psychosis such as schizophrenia or mania.  If the patient had been attacked by chronic hepatitis but systemic TCM therapy was instituted in time, clinical psychotic symptoms like disorder of thought may be alleviated.

Introduction of cases

Case 1

Yang, female, age 36 years.  She first visited the clinic in October 1994 with the complaint of pregnancy for 2 more months associated with frequent vomiting, occasional cough, repeated epistaxis and constipation.  Physical examination: shrinkage of liver to 4.5 cm. above costal margin.  She took 12 parcels of TCM drugs and the symptoms disappeared.  She had a return visit 3 months later and was found to have hepatomgaly of 1.5 cm.  After taking 15 parcels of TCM drugs, the liver was normal and another 10 parcels were taken before cessation of medication.

In June, 1995, she delivered a female baby.  At four months postpartum, she made a return visit because of depression and frequent insomnia, fatigue, vertigo, anxiety, distension of abdomen, repeated cough with abundant sputum.  Her lower lips showed varicella because of hypersensitivity and she also had pruritus of the above region.  Western medical drugs did not show effectiveness.  The diagnosis was chronic hepatitis, urticaria, postpartum depression, with TCM classification of liver stagnation and lung dryness.

Physical examination: tongue coating yellowish, skin of lower jaw slightly red maculopapular eruptions with urticarial appearance, hepatomegaly of 1.5 cm, percussion tenderness of hepatic region.  After taking 6 parcels of TCM drugs, the liver returned to normal, the symptoms disappeared and the skin was normal.  TCM drugs were continued for four weeks, at the end of which clinical cure was obtained.  The patient was followed up after stoppage of treatment.

Lai, female, age 47 years.  First visit: December 2002.  Her husband was a carrier of type A hepatitis virus.  Her blood examination showed positive type B hepatitis antibodies.  Her body status was of the weak type; she was susceptible exopathy and had excessive sputum.  Her cough was severe and spasmodic and caused occasionally a vertigo like sensation.  In the recent two years, her emotion was unstable; she had flush, dryness of throat, edema, insomnia, pruritus vulva, leukorrhagia and nocturnal perspiration.  She was diagnosed by specialists as emotional disease and was given long term anti-depression drugs.

Physical examination: hepatomegaly of 3 cm, (+++) pitting edema of lower extremities.  The diagnosis was liver stagnation and lung dryness, wetness-heat vaporization, chronic hepatitis, hepatic psychoneurotic disease.

When 3 parcels of TCM drugs were taken abdominal pain and diarrhea occurred thrice a day; cough and sputum decreased.  Her body weight decreased and the liver was normal.  Edema greatly regressed.  After another 3 parcels of TCM drugs, there was occasional abdominal pain and diarrhea was still thrice a day.  There was still some coughing but sorethroat and sputum lessened and sleeping was well.  Anti-depression drugs were stopped but she woke up early.  Bowel movements were normal.  Continuation of TCM drugs resulted in disappearance of edema of lower limbs.  She slept well and could fall into sleep again shortly after wakening.

After taking 10 parcels of TCM drugs, her body weight reduced 5 lbs.  Menstruation appeared at the fourth week of medication, the amount decreased but clots were present and the menses persisted for nearly four days.  She no longer experienced fatigue.  She completed a TCM course of four weeks, by that time she achieved clinical cure and was followed up.

Tsang, female, age 36 years.  She made her first visit in April, 1998 with the complaint that she received thyroid operation for hyperthyroidism 10 more years ago.  During this period she suffered from severe insomnia, sleeping for only 3 hours a night.  She was susceptible to attacks of common cold, palpitation, tremor of hands, sensation of foreign body in the throat.  Sleeping pills and anti-depression drugs were of no avail.  She had an abortion a year ago followed by repeated secretion of milk in both breasts.

Physical examination: hepatomegaly of 3 cm, (+) edema of lower extremities.  The diagnosis was chronic hepatitis, hepatic psychoneurotic disease, hepatopathic upper respiratory tract infection, disorder of menstruation, hepatic edema, hepatogenic sexual hormone disorder, hyperthyroidism.  After taking 3 parcels of TCM drugs, the liver was normal.  At the completion of a TCM therapeutic course, she obtained clinical cure.

Au, female, age 40 years.  First visit: December 2000.  She complained that since delivery of a female infant, she suffered from postpartum depression; she had mental stress, palpitation, anxiety, insomnia as well as dreamfulness.  She had bilateral hypochondriac pain, tiredness of shoulders and back and sensation of a sound ringing in the head (especially during sleep).  She now had swelling and pain of the gingivae, belching, chest and hypochondriac pain, increase of white hairs and flush of face.  Repeated WM and TCM treatment showed no effectiveness.

Physical examination: flush of face, tenderness over right second sternacostal articulation, hepatomegaly of 3 cm, (±) edema of extremities.  The diagnosis was chronic hepatitis with TCM classification of flaring up liver yang, deficiency of both liver and kidney, postpartum depression.

After taking 3 parcels of TCM drugs, the liver was normal.  Her sleeping improved but flushes of face and anxiety and hypochondriac pain was present.  During TCM drug administration, there was still some mental stress associated with bitterness of taste.  Two weeks later, flush of face disappeared and sleeping was good.  At her return visit the symptoms disappeared besides slight shoulder and hypochondriac pain.  Menstruation occurred, the amount slight increased with some clots.  Physical examination: local tenderness over left shoulder and right second stern costal articulation, liver normal.  At the 4^th week of therapy, she suffered from diarrhea before sleep for several days; the stools were watery, one to three times a day.  A total of 48 parcels of TCM drugs were taken and it brought her the result of clinical cure.  The patient was followed up.

By WONG Kwok Hung

Published on 30th January 2003

Translated by Professor Zheng in June 2005