Friday, June 15, 2012

Acupuncture and Herbs for Mind and Brain Disorders II

In many cases, disorders that involve a defect in brain function require continuous therapy.  In modern medical practice, patients with mind-brain disorders may be given drugs that are taken for years or for life.  It is rarely practical to utilize acupuncture over such an extended period of time, so herbal therapies become an important consideration.  Since some people live far from a site where acupuncture is offered, herbal remedies may be the only viable method of traditional medicine to be prescribed, other than simple exercises that can be done daily, such as those derived from the practices of taiji and qigong.
BASIC THERAPEUTIC APPROACHES
The Chinese literature includes numerous reports about the treatment of mind and brain disorders with herbs, the most common subject by far being the treatment of senile dementia.  This will be the focus of the current presentation. For mind/brain disorders that occur earlier in life, the treatment method for attention deficit disorder serves as a model; also, the book Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs (1) provides information on herbal therapy for schizophrenia and several other mental disorders.
In general, it can be said that there are three component therapeutic approaches that have long been relied upon in traditional Chinese medicine to address the problems characteristic of senile dementia:
1.     Tonification therapy.  The brain is described as an extension of the marrow which belongs to the kidney system, so herbs that nourish the kidney are understood to nourish the brain.  Lack of nourishment of any organ can lead to mental distress, due to the fact that the internal spirits cannot rest if their associated internal organs are “empty,” that is, deficient in essential fluids.  In particular, deficiency of liver and heart can easily cause disturbance of the mind.  Weakness of spleen qi is often ultimately responsible for lack of nourishment; the spleen must also promote upward circulation of qi to reach the brain.
2.     Clearing orifices of phlegm-mist.  The connection between the heart and mind (or body and brain) is made by channels (orifices) that can become obstructed; the source of obstruction may be weak stomach/spleen function leading to accumulation of phlegm or fire syndrome damaging fluids and transforming them to pathological phlegm.  Aromatic and penetrating herbs can clear the obstruction and phlegm-resolving herbs can help prevent the orifices from becoming obstructed again.
3.     Calming agitation.  Aside from the problem of deficiency that leads to unsettling of the spirit, the mind can be agitated as a result of heat, wind, or uprushing qi and yang, disorders that may be secondary to deficiency (e.g., yin deficiency of the liver yields liver fire and internal wind) or may be an excess pattern.  Herbs are used to clear the heat, sedate the wind, and settle the upward rising of qi and yang. 
It is common to combine all these therapies in a single formulation because each of the pathological conditions will often be present to a certain extent in elderly patients. Throughout the history of Chinese medicine, several mental disorders, including loss of consciousness, mania, and emotional agitation, were understood to occur as the direct result of feverish diseases.  Thus, herbs that purge fire, including rhino horn, raw rehmannia, coptis, gardenia, and scute, were sometimes key ingredients in the prescriptions.  In modern times, most of these feverish conditions can be controlled with antibiotics, antipyretic drugs, and other modern therapies so that the mind and brain disorders that are the subject of potential Chinese-herbal treatment today are rarely associated with febrile disease. While these same fire-purging herbs have some sedative effects, it is clear from the ancient formula descriptions that they were included mainly for their role in treating a febrile condition.  This fire-purging aspect of treatment is not discussed further in this article.
As is the case with many other diseases, modern Chinese practitioners have added to the traditionally employed methods the principle of treating blood stasis as a means of resolving mind-brain disorders.  Frequently used herbs, such as red peony, cnidium, persica, carthamus, and salvia are the most frequent additions for this purpose.  Since blood-vitalizing therapy is a new method for treating mental disorders (except in the syndrome xue dao zheng, see: Complex disease patterns), it will only be noted later in this article in the section devoted to modern journal reports.  A Chinese herb adopted into the practice of Western herbal medicine, ginkgo leaf, has become well-known for promoting circulation to the brain.  The circulation improvement may restore some of the affected mental functions (see: Ginkgo).  Presumably, the blood vitalizing herbs have a similar action.
Tables 1–3 list some sample herbs in each of the three therapeutic areas of primary concern.  The herbs were selected for inclusion on the basis of high frequency of use in treating mind and brain disorders as described in both the traditional and modern literature.  Within each category, the herbs are listed alphabetically by common name (followed by pinyin for clear identification).  In the section of “main actions,” the information is derived from Oriental Materia Medica (2), with only those actions that are somewhat relevant to treatment of mental disorders included in the table.

Table 1: Tonic Therapies Frequently Used for Mind and Brain Disorders.
Herb
Main Actions
Comments
Alpinia
yizhiren
supplements spleen, warms the kidney, astringes essence, strengthens the stomach, fortifies qi
The Chinese name for the herb means to enhance the disposition of the individual (increase wisdom, is one translation).  It is thought to improve the thinking function associated with the spleen and the will associated with the kidney.
Asparagus
tianmendong
nourishes yin, moistens dryness
Asparagus is considered similar in nature, taste, and function to ophiopogon and is commonly used in combination with it to nourish the yin.
Astragalus
huangqi
supplements qi, increases yang
Astragalus helps the spleen generate a pure and clear qi that rises upward to nourish the heart and brain
Atractylodes
baizhu
supplements spleen, tonifies qi
This aromatic tonic for the spleen disperses stagnated fluids that can obscure the heart orifices.
Cistanche
roucongrong
nourishes kidney essence, supplements yang
The soft, black, salty herb is thought to quickly nourish the deficient kidney essence.
Codonopsis
dangshen
invigorates the spleen and stomach, replenishes qi
In China, codonopsis is almost always used as a substitute for ginseng in modern practice; its action is more focused on rectifying stomach/spleen weakness, but it lacks the sedative qualities of ginseng.
Cornus
wuzhuyu
supplements liver and kidney, astringes essence
The sour fruit is frequently used to astringe the essence and help prevent deterioration of health.
Cuscuta
tusizi
supplements kidney essence, clears vision
The seed is thought to help prevent leakage of essence (like the astringent herbs), therefore it is used to prevent deterioration.
Dioscorea
shanyao
supplements spleen and stomach, tonifies lungs and kidneys, astringes essence
Dioscorea is used in many treatments for weakening of the kidney essence; its ability to benefit the spleen at the same time is unusual among the Chinese herbs used for that purpose.
Ginseng
renshen
replenishes and supplements original qi, benefits the five viscera, pacifies the spirit, soothes the soul, increases wisdom, opens the cleverness of the heart, clears vision
Ginseng is one of the original remedies for mental disorders used in Chinese medicine; it has a calming nature and replenishes all deficiencies.  In the West, ginseng has taken on the connotation of an energy stimulant, partly due to the erroneous translation of qi as energy.  As a result, practitioners and patients often worry about the stimulant action of this herb.
Ho-shou-wu
heshouwu
nourishes yin, replenishes essence and blood, tonifies liver and kidneys
Ho-shou-wu is a famous “anti-aging” herb that is reputed to keep the body and mind young and active.  By nourishing the kidney and liver, it nourishes the brain.
Hoelen
fuling
strengthens spleen, harmonizes middle warmer, tranquilizes the heart, soothes the nerves, and pacifies the spirit
Hoelen is favored as a sedative, especially when there is weakness of the stomach/spleen system.  It has a mild action.
Longan
longyanrou
supplements the heart, stabilizes the spirit, tonifies spleen, nourishes blood
This sedative tonic has properties that imitate the actions of ginseng plus tang-kuei.  It is primarily used in Ginseng and Longan Combination (Guipi Tang).
Lycium
gouqizi
supplements liver and kidneys, promotes production of jing and blood
Lycium is commonly used in cases of jing deficiency and is considered especially useful because of its mild nature, not producing any adverse effects even in large dosage.
Ophiopogon
maimendong
nourishes yin, moistens dryness, removes heat, resolves phlegm
This yin-nourishing herb is especially relied upon when there is phlegm accumulation and heart agitation, as it has both phlegm-resolving and calming properties; sometimes asparagus is added to enhance the heat clearing action.
Peony
baishao
supplements blood
Peony is frequently used in formulas that tonify spleen qi and nourish liver blood; it has an affinity for the spleen and liver, where it can enhance the action of the other herbs.
Rehmannia
shoudihuang
nourishes blood and essence, supplements kidney and liver
This rich, black processed root is considered one of the most important herbs to nourish the liver and kidney.  It is used to prevent and even reverse the deterioration associated with aging.
Schizandra
wuweizi
nourishes the kidneys, astringes essence
Like cornus, it is relied upon to astringe essence and prevent deterioration of health; modern research has shown that it normalizes cerebral electrical discharges and is thus used in treatments for brain disorders, especially those involving insomnia and poor memory.
Tang-kuei
danggui
supplements and moves blood
This herb is used for nourishing the blood of the liver and heart, which has the effects of controlling emotional distress and relieving spasms.

Table 2: Sedative Herbs Commonly Used for Mind and Brain Disorders.  For a more comprehensive list of herbs that calm mental agitation see: Emotions and health.  Polygala, listed in the Materia Medica among the heart-nourishing herbs, has been moved to the category of herbs to help resolve phlegm mist, because of its well-known phlegm-resolving action (see Table 3).
Herbs
(Pinyin)
Main Actions
Comments
Biota
baiziren
nourishes heart and calms mind
This seed is very oily, so it is used only moderately or left out if there is a spleen-damp syndrome, but is favored for constipation and dryness.
Cinnabar
zhusha
sedates the heart and calms the mind
This is the premier sedative of the Chinese tradition and mentioned in numerous ancient and modern formulas; however, it is avoided in the West due to its content of mercury, the active constituent.
Dragon bone
longgu
pacifies the liver, restrains floating yang, sedates and calms the mind
These are fossilized bones, comprised mainly of soluble minerals, such as calcium carbonate.  It has a nutritive and calming action.
Dragon teeth
longchi
sedates and calms the spirit
Like dragon bones, dragon teeth are fossilized; they are the huge teeth of mastodons and other creatures that have long since disappeared.  Chinese doctors regard them as especially useful for fright-induced mental disorders.
Fu-shen
fushen
sedative
Fu-shen is mostly the same material as hoelen (see Tonics) but includes portions of pine root; the pine confers a sedative effect.
Oyster shell
muli
pacifies the liver and restrains the floating yang
Oyster shell is the principal ocean shell used in Chinese medicine, though several others are also used and have similar actions; they contain calcium carbonates and are used to calm agitation.  They also are used to reduce excess stomach acid.
Succinum
hupo
sedates and calms spirit
This is the aged resin of pine; the Chinese say that this material is actually the soul of tigers that have died, and it has a sedating quality that still imparts the tiger’s power.
Zizyphus
suanzaoren
nourishes heart and calms spirit
The most commonly-used liver-nourishing sedative in Chinese medicine, it treats most mental disorders characterized by insomnia and agitation.

Table 3. Herbs that Clear Phlegm Mist and Open the Orifices.  This table includes herbs found in the Materia Medica categories of opening orifices and of resolving phlegm.  One herb, curcuma, is usually categorized as vitalizing blood, but it is included in formulas for brain disorders because of a cooling, phlegm-resolving action.
Herb
(Pinyin)
Main Actions
Comments
Acorus
changpu
opens orifices, expels phlegm and turbidity, replenishes intelligence
This is the most commonly-used Chinese herb (of plant origin) for treatment of mental disorders.  It was listed in the Shennong Bencao Jing as a superior herb and it also has symbolic value as a dispeller of evil spirits.
Arisaema
tiannanxing
dispels wind to relieve convulsions, dries dampness to resolve phlegm, disperses lumps and accumulations
Arisaema is described as having the power to vaporize phlegm accumulations; it is mainly used when the herbal formula is aimed at treating phlegm obstruction of the orifices.  The bile processed arisaema, known as dannanxing, has a cooling rather than warming nature.
Bamboo
zhuru, zhuli, tianzhuhuang
removes heat, transforms phlegm, calms fright
Bamboo leaves, juice, or dried secretion are all used to treat irritability, fidgets, and convulsions.  They are particularly favored in treatment of children’s disorders.
Borneol
longnao
opens orifices, moves qi, clears vision
Borneol is usually used as an adjunct ingredient in formulas for resolving phlegm that causes brain disorders; it is often combined with musk and/or acorus to open orifices.
Curcuma
yujin
regulates flow of qi, dissolves qi stagnation, disperses stagnant blood
Although curcuma is best known for its ability to vitalize circulation of qi and blood, it enters into several formulas for brain disorders because it is also considered useful in treating phlegm accumulation disorders, especially when there is a heat syndrome.
Musk
shexiang
opens orifices
Musk, with its penetrating aroma and stimulating quality, is mostly used for the very severe cases of brain disorder, especially when the person is losing consciousness or suffering from severe delirium.
Ox gallstone
niuhuang
opens orifices, transforms phlegm, clears heat, removes toxin, calms fright
Ox gallstone is utilized to correct gallbladder disorders that result in hot phlegm moving upward to cloud the consciousness.  A mixture of bile acids and minerals is used today to make synthetic ox gallstone to replace the extremely rare and expensive original compound.
Pinellia
banxia
harmonizes stomach, dries dampness, removes phlegm, disperses accumulation
Pinellia is the most commonly-used phlegm-resolving herb in Chinese medicine and it enters into formulas for treating brain and mind disorders that involve phlegm accumulation due to stomach/spleen weakness.
Platycodon
jiegeng
resolves phlegm
Platycodon is thought to direct the action of other herbs to the upper body, and it is, therefore, useful in treating brain disorders; in addition, it helps to resolve phlegm accumulation that is often associated with diseases of the brain.
Polygala
yuanzhi
stabilize the heart and calm the mind
Polygala is often used as an adjunct to acorus for resolving phlegm that obstructs the orifices of the heart.  In addition, it is used as a sedative, often along with zizyphus.
SAMPLE FORMULAS: TRADITIONAL PRESCRIPTIONS AND PATENT REMEDIES
The formulas described below were designed for mind and brain disorders that arise from a nutritional and functional deficiency of the internal organs.  The herb ingredients are divided according to the three categories of therapy outlined above; most of the formulas have additional ingredients that do not fit into these categories and are not listed here.  For complete ingredients listings, please see the reference texts (3, 4).  Descriptions of modern patents may involve partial ingredients lists and should be interpreted with some reservations.  After each presentation of the formula ingredients by therapeutic category, there is a very brief description of the formula.  For problems in mind/brain function that are associated with imbalances in the seven emotions, stagnation of qi and blood, and accumulation of moisture, see the article: Complex disease patterns, which presents a different selection of herbal formulas.
Niuhuang Qingxin Wan (Bos and Musk Formula)
Tonics
Sedatives
Orifice-clearing Herbs
Atractylodes
Cinnabar
Musk
Tang-kuei

Borneol
Peony

Ox gallstone
Ginseng

Platycodon
Hoelen

Curcuma
Dioscorea


Ophiopogon


Bos and Musk Formula is used for loss of consciousness, stroke, extreme emotions (anxiety, fright, grief), irritability, insomnia, abnormal mood swings, and mental confusion.  An older version of this formula has a large number of tonic herbs, probably to help restore fluids damaged by a prolonged febrile disease (treated by ingredients such as coptis, scute, and gardenia).
Tianwang Buxin Dan (Ginseng and Zizyphus Formula)
Tonics
Sedatives
Orifice-clearing Herbs
Schizandra
Zizyphus
Platycodon
Tang-kuei
Biota
Polygala
Rehmannia
Cinnabar

Ophiopogon


Asparagus


Ginseng


Hoelen


Ginseng and Zizyphus Formula, probably the best known of the prescriptions in this group, is used for poor memory and insomnia.  Cinnabar is used only to coat the outside of the traditional pills.  This prescription is commonly prescribed in the West (cinnabar is usually deleted).  It is considered suitable for long-term therapy in treating chronic brain disorders, such as occur with aging.  The main emphasis of this formula is tonification of yin and blood.  A formula originally developed to tonify the spleen, Guipi Tang (Ginseng and Longan Combination), has been adopted to a similar application.  It has ginseng, hoelen, tang-kuei, zizyphus, and polygala in common, but includes several other qi tonics (astragalus, jujube, atractylodes, licorice) in place of the yin-nourishing herbs of Ginseng and Zizyphus Formula.
Bu Nao Wan (Cerebral Tonic Pills)
Tonics
Sedatives
Orifice-clearing Herbs
Schizandra
Zizyphus
Acorus
Tang-kuei
Biota
Arisaema
Cistanche
Succinum
Polygala
Lycium
Dragon teeth

Cerebral Tonic Pills is a modern patent remedy indicated mainly for poor memory and insomnia.  The emphasis of this formula is sedative effects, useful for anxiety, heart palpitations, and being easily frightened.
Jian Nao Wan (Healthy Brain Pills)
Tonics
Sedatives
Orifice-clearing Herbs
Schizandra
Zizyphus
Acorus
Tang-kuei
Biota
Bamboo
Cistanche
Cinnabar
Polygala
Ginseng
Succinum

Alpinia
Dragon teeth

Lycium


Dioscorea


Healthy Brain Pills is a modern patent designed along the same lines as Cerebral Tonic Pills, and for the same indications.  The acorus used is known as altaica (jiujie changpu), from a different plant.  This formula includes gastrodia (see section on gastrodia below).
Baizi Yangxin Wan (Biota Heart Nourishing Pills)
Tonics
Sedatives
Orifice-clearing Herbs
Schizandra
Zizyphus
Pinellia
Tang-kuei
Biota
Polygala
Hoelen
Cinnabar

Biota Heart Nourishing Pills is a patent remedy that represents a variation of the traditional Ginseng and Zizyphus Formula (Tiawang Buxin Dan); numerous factories produce sedative formulas in which they attempt to improve on this widely-used prescription.  The ingredients list is probably incomplete.
Anshen Yuanzhi Wan (Pacify Spirit Polygala Pills)
Tonics
Sedatives
Orifice-clearing Herbs
Ginseng
Dragon’s teeth
Acorus
Hoelen
Fu-shen
Polygala
There are several traditional formulas similar to Anshen Yuangzhi Wan, including Yuanzhi Wan (Polygala Pills; slightly different proportions of same ingredients) and Dingzhi Wan (Emotion Controlling Pills; cinnabar replaces dragon’s teeth), all of which have the same indications: to calm mental agitation.
Ping Bu Zhenxin Dan (Calming and Sedating the Heart Pill)
Tonics
Sedatives
Orifice-clearing Herbs
Ginseng
Dragon’s teeth
Polygala
Ophiopogon
Fu-shen

Schizandra
Zizyphus

Dioscorea
Cinnabar

Asparagus


Rehmannia


Hoelen


The Calming and Sedating Pill, with its large group of tonic herbs, is mainly used in cases of essence deficiency, where the person is easily frightened, has heart palpitations, and fatigue.
Yangxin Tang (Heart Supporting Decoction)
Tonics
Sedatives
Orifice-clearing Herbs
Ginseng
Zizyphus
Polygala
Hoelen
Fu-shen
Pinellia
Schizandra
Biota

Astragalus


Tang-kuei


Yangxin Tang is an example of a formula that is virtually all tonic in nature.  Each of the herbs, despite the category listed, has a nourishing action affecting one or more of the zang organs.  Therefore, it is used in persons who are weak and thin and have trouble getting adequate nutrition.
Sheng Tie Luo Yin (Iron Filings Decoction)
Tonics
Sedatives
Orifice-clearing Herbs
Hoelen
Fu-shen
Acorus
Ophiopogon
Cinnabar
Polygala
Asparagus

Arisaema
This formula is aimed at the treatment of upflaring phlegm-fire, in which the fire is secondary to yin deficiency.  The imbalance often gives rise to a variable mental condition, such as manic-depressive disorder.  When the fire dominates, a manic condition is present; when the phlegm dominates, a depressive condition arises.
REVIEW ARTICLES ON HERBAL THERAPIES FOR SENILE DEMENTIA
Two review articles published in the Journal of Traditional Chinese Medicine are elaborated here in order to summarize a broad range of Chinese medical literature.  Due to the length of the review articles and diversity of therapeutic categories and formulas offered, certain portions were selected for presentation.  
In a 1996 review of Chinese herbal therapies for senile dementia (5), doctors at the Chengdu University of Traditional Chinese Medicine and Pharmacy presented the following summary (Table 4) of syndromes and key herbs that reveal the current therapeutic approaches.
Table 4: Modern Differential Diagnosis and Treatment for Senile Dementia.
Syndrome
Main Symptoms
Key Herbs
Deficiency of kidney essence
progressive dementia, dizziness, tinnitus, insomnia, poor memory, difficulties in speech, dull eyes, and slow responses
rehmannia, cornus, dioscorea, ho-shou-wu, lycium, eucommia, tang-kuei, zizyphus, polygala
Stagnation of phlegm
dull expressions, vague mind, depression, poor memory, abnormal behavior, involuntary crying or laughing, dizziness, heavy sensation of the head or limbs, chest distress, poor appetite, sleepiness
pinellia, hoelen, acorus, polygala, citrus, curcuma, bamboo, bamboo sap, chih-ko, angelica
Deficiency of qi and blood
dizziness, poor memory, indifferent expression, dreaminess and light sleep, susceptible to fright, pale complexion and listlessness, unable to participate in normal daily activities
ginseng (or codonopsis or pseudostellaria), astragalus, tang-kuei, atractylodes, fu-shen, rehmannia, ho-shou-wu, polygala, peony, zizyphus
Cerebral blood stasis
dizziness, headache, poor memory, dementia, stiff tongue and incapability of uttering a sound, history of apoplexy, facial hemiparalysis, hemeplegia
salvia, carthamus, persica, cnidium, astragalus, angelica, musk, tang-kuei, red peony
The authors suggested that there are two main actions of the herbs that are used in the formulas: to replenish the kidney, and to supplement and invigorate qi and blood.  They translated the means by which these actions affect dementia to a Western idiom as follows:
1.     To supply substances needed by the brain and nerve cells to carry out normal metabolism and regulate cerebral activities; and
2.     To invigorate the following activities: blood supply to the heart, immunologic functions, detoxification of the liver, nutrient absorption of the alimentary system, and utilization of energy by the body to improve the nutritional and metabolic state, or, in other words, to regulate the vitality of the whole body to improve mental function and combat senility.
The overall effects of the herbal therapies, they claimed, were: “strengthening the body activities to combat or retard senility of organs in the body, and to facilitate elimination of pathological products resulting from the hypofunction of an organism.”  The authors also suggested that if blood-vitalizing herbs are included with the tonic therapies that the results will be even better than using tonics alone, mainly because of the improved microcirculation.  Two case examples were presented, in which patients over 80-years-old were given decoctions to take for about one month in order to get substantial improvements in mental and physical conditions.
In a 1999 review from the Ningjin County Hospital of Traditional Chinese Medicine (6) journal reports were divided into four groups: treatment based on general differentiation; treatment based on differentiation of regulating and nourishing the kidney and heart; treatment based on differentiation of blood stasis and phlegm obstruction; and treatments based on specific formulas.  In this presentation, a number of the prescriptions are designated by their traditional name (see the Appendix for ingredients lists for most of the formulas) and many were said to be “modified” without specifying the alterations made.
1. Treatment Based on General Differentiation
Several examples of this approach were offered, the one attributed to a 1994 article by Dr. Wang Hengsong is as follows, giving the diagnostic category and recommended formula for treatment:
·       Deficiency of brain and spinal cord: Modified Bushen Yisui Tang (Decoction for Tonifying the Kidney and Rectifying the Marrow);
·       Deficiency of heart and spleen: Guipi Tang (Ginseng and Longan Combination);
·       Hyperactivity of heart fire and liver fire: Modified Tianma Gouteng Yin (Gastrodia and Uncaria Formula) plus Huanglian Xiexin Tang (Coptis Combination);
·       Yin deficiency of liver and kidney: Modified Qi Ju Dihuang Tang (Lycium, Chrysanthemum, and Rehmannia Formula) plus Dingzhi Tang (Emotion-calming Decoction);
·       Stagnation and obstruction by phlegm and blood stasis: Modified Banxia Baizhu Tianma Tang (Pinellia and Gastrodia Combination); and
·       Stagnation of qi and blood: Modified Xiaoyao San (Bupleurum and Tang-kuei Formula) plus Tongqiao Huoxue Tang (Decoction for Activating Blood Circulation).
In the other approaches to general differentiation of syndromes by various authors, the categories differed somewhat (usually, there were 4–6 categories) and the specific formulas used also varied.  Here are two sets of recommendations, the first attributed to a 1995 article by Xu Shizhen, the second attributed to a 1994 article by Dr. Zhao Xiangjun:
Category
Xu Shizhen’s Recommendations
Liver/Kidney Yin Deficiency
Modified Bushen Yinao Tang
Spleen/Kidney Yang Deficiency
Modified Yougui Wan
Accumulation/Obstruction by Phlegm
Modified Erchen Tang
Interior Obstruction by Blood Stasis
Modified Fuyuan Huoxue Tang

Category
Zhao Xiangjun’s recommendations
Failure of Kidney Essence
Modified Yougui Wan
Liver/Kidney Yin Deficiency
Modified Zuogui Wan
Heart/Spleen Deficiency
Modified Guipi Tang
Obstruction by Phlegm and Blood Stasis
Mengshi Guntan Wan plus Xuefu Zhuyu Tang
2. Treatment by Regulating and Nourishing Heart and Kidney
The following self-designed base formulas were offered in a 1995 article by Lin Changxing and colleagues:
·       Insufficiency of heart qi: codonopsis, hoelen, licorice, acorus, polygala; and
·       Deficiency of kidney yin: asparagus, ophiopogon, rehmannia (cooked and raw), cornus.
Dr. Yao Peifa, in a 1992 article, offered these therapeutic categories and formulas:
·       Reinforcing kidney and replenishing essence: rehmannia, lycium, ho-shou-wu, curculigo, epimedium, acorus, polygala;
·       Nourishing kidney and eliminating phlegm: Modified Dingzhi Wan and Yougui Wan;
·       Nourishing the kidney, removing blood stasis: rehmannia, ho-shou-wu, lycium, cyathula, persica, carthamus, cnidium, earthworm, cyperus, acorus, polygala; and
·       Nourishing yin and eliminating phlegm: rehmannia, ho-shou-wu, ophiopogon, forsythia, bamboo, coptis, pinellia, curcuma, acorus, polygala, salvia.
3. Treatment Based on Differentiation of Blood Stasis and Phlegm Accumulation
Two articles were described in this section of the review, one was a 1995 publication of Yan Qianlin that focused on blood stasis, and the other a 1995 article by Zhang Jueren focused on phlegm obstruction:
Category
Yan Qianlin’s Recommendations
Obstruction of phlegm and blood stasis
modified Huanglian Wendan Tang and Tongqiao Huoxue Tang
Stagnation of qi and blood stasis
modified Dian Kuang Mengxing Tang
Qi deficiency and blood stasis
modified Yiqi Congming Tang plus Tao Hong Siwu Tang
Marrow deficiency and blood stasis
Xingnao Yizhi Tang

Category
Zhang Jueren’s Recommendations
Upward attack of wind-phlegm
Banxia Baizhu Tianma Tang plus Changpu Yujin Tang
Phlegm preventing lucid yang to rise
Banxia Baizhu Tianma Tang plus acorus, kao-pen, angelica
Phlegm and blood stasis obstructing collaterals
Banxia Baizhu Tianma Tang plus acorus, kao-pen, angelica, plus modified Buyang Huanwu Tang
Phlegm due to deficiency
modified Banxia Baizhu Tianma Tang plus modified Changpu Yujin Tang
4. Treatment by Specific Prescriptions
The following information is based on reports in which a single base formula was utilized for cases of senile dementia, rather than relying on differential diagnosis.  The formulas are presented here according to the therapeutic approach that was utilized for the patients.  In many cases, the formula was then modified slightly to address the unique symptoms of the patients:
Therapeutic Category
Formula Ingredients
Supplementing qi and activating blood circulation to remove stasis
astragalus, cnidium, red peony, peony, persica, pueraria, millettia, codonopsis, acorus, curcuma, alpinia, polygala
Nourishing the kidney and brain
modified Dihuang Yinzi
Nourishing the kidney and brain
ho-shou-wu, cornus, dioscorea, lycium, cuscuta, red peony, salvia, curcuma
Tonifying the kidney, supplementing qi, and activating blood circulation
astragalus, codonopsis, pueraria, salvia, crataegus, lycium, polygonatum, cornus, tang-kuei, gastrodia, acorus
Tonifying the kidney, supplementing qi, and activating blood circulation
astragalus, salvia, codonopsis, alpinia, acorus, lycium, ho-shou-wu, polygala, red peony, cnidium
Tonifying the kidney and activating blood circulation to remove stasis
cornus, cuscuta, alpinia, curcuma, arisaema, polygala, acorus, placenta, leech, crataegus
Tonifying the kidney and activating blood circulation to remove stasis
rehmannia, cistanche, tortoise shell, cornus, polygonatum, curcuma, tribulus, silkworm, gastrodia, astragalus, acorus, arisaema, carthamus
Dispelling phlegm and removing blood stasis
Wendan Tang plus acorus, curcuma, silkworm, arisaema, gastrodia, salvia
Dispelling phlegm and removing blood stasis
astragalus, red peony, cnidium, persica, earthworm, curcuma, acorus, polygala, bamboo, aurantium, pinellia, carthamus, gastrodia, silkworm, scorpion, leech, centipede
The authors of the review commented:
TCM holds that while the location of the disease is in the brain, its root cause is insufficiency of vital essence and energy of various zangfu organs in addition to obstruction by stagnation of phlegm and blood stasis.  The weak constitution due to old age often leads to weakness and failure of the zangfu organs and deficiency of qi and blood and deficiency of yin and yang.  This weakness and failure may give rise to stagnation of qi, causing blood stasis, which, in turn, leads to accumulation of qi to form phlegm that may retain in the five zang organs and obstruct collaterals of the brain to confuse the mind, hence the occurrence of dementia.  Its pathogenesis is deficiency in origin and excess in superficiality.
EFFECTS OF TREATMENT
Chinese clinical reports depict reasonably-high success rates (describing some patients as markedly improved, others as improved), but what is the specific expectation?  A recent clinical trial carried out at the TCM Hospital of the Luzhou Medical College (7) is indicative and will be used here as an example in which there is more detailed reporting by the researchers than is usually found.
The disorder category under consideration was senile dementia in patients over age 60.  Criteria for inclusion were symptoms such as disturbances in memory; difficulty making calculations or getting oriented to surroundings; marked emotional or personality changes; and a slow or progressive course of the symptoms lasting more than six months.  From the TCM viewpoint, participants had to fit into the deficiency (consumptive) type of disorder.  Thus, all patients suffered from a deteriorating physical and mental health for at least six months.  The patients were sub-grouped by symptom patterns according to three TCM categories of yang deficiency of spleen and kidney; deficiency of qi and blood; or deficiency of yin and yang.  The patients were randomized to Chinese herbal or Western medical treatments and the patients were equally represented within the diagnostic groupings for both treatment methods.  In general, patients with the spleen- and kidney-yang deficiency or deficiency of qi and blood had mild to moderate dementia, while those with deficiency of yin and yang had more severe dementia.
The patients treated by Western medicine (31 patients) received centrofenoxine, gamma-aminobutyric acid, and folic acid.  The patients treated by herbs (34 patients) received Yu Cong Tang, a decoction of the following: astragalus, codonopsis, atractylodes, rehmannia, drynaria, cistanche, aconite, epimedium, cnidium, cyathula, pinellia, arisaema, and acorus.  The treatment time for the study was 30 days.
This short treatment time is not deemed sufficient for evaluating therapies by Western standards: drug evaluations for senile dementia usually involve a minimum treatment time of six months, and to make a decision about suitability of the treatment method, administration for one to two years is often required.  Nonetheless, when patients seek help with Chinese medical techniques in the West, a prompt response, within one month, is usually important in order to decide whether to continue the therapy.  In this study, a six-month follow-up after completion of the treatment was made for patients who opted to continue taking the herbs or drugs.
The physicians tested the patients for remote and recent memory, understanding, orientation of time and space, calculation ability, and compliance.  They performed CT scans of the brain, as well as EEG and REG tests (detecting brain waves and blood flow, respectively).  They also took blood samples to evaluate blood oxygenation, hemoglobin, and other parameters.
For the performance tests, the report indicated no differences between the two treatment groups prior to treatment, and no improvement in the Western medicine group after treatment.  A statistically significant improvement in all five performance tests were claimed for the Chinese herb group.   The same result was claimed for the CAT scans, EEG, and REG, though the most significant improvement was in the blood flow measurement.  Among the blood factors assayed, the most significant improvement was in hemoglobin levels, which increased markedly in the Chinese herb group, but decreased slightly in the Western medicine group.  Summarizing the results of one month of treatment with herbs, the authors indicated that in mild and moderate cases of the disease, all the patients showed improvement, while in severe cases only 40% showed improvement with herbal therapy. 
During follow-up, it was reported that “25 cases in the TCM group persisting in taking Yu Cong Tang were spiritually good, could take care of daily life, and the scores of tests on remote and recent memory, orientation, calculation and understanding kept in the range of being markedly effective.  Brain CT was performed in 13 cases and only a mild degree of brain atrophy was found.  Of the 9 cases who did not continue the therapy, 3 died of secondary infection, 2 could not take care of their daily life, and 4 became worse.”  The authors concluded:  “In clinical practice, it is essential to prevent and treat deficiency of the organism because the severity of dementia is proportional to the deficient state of the organism.”
USE OF GASTRODIA IN BRAIN DISORDERS
One of the ingredients frequently mentioned in the treatments for senile dementia that does not quite fit the therapeutic patterns usually mentioned is gastrodia (see: Gastrodia).  The reason for its inclusion is its strong reputation for ability to treat a wind-phlegm disorder.  This disorder usually causes symptoms of muscular incoordination, with spasms, convulsions, or repetitive movements.  The spasms can manifest as headaches and hypertension, the convulsions can manifest as epileptic seizures or irregular movements, and the repetitive movements can manifest as Parkinsonism.   To treat wind-phlegm, Chinese herbalists usually tonify the spleen (e.g., with ginseng and atractylodes), resolve phlegm (e.g., with pinellia and citrus), and settle wind (e.g., with gastrodia and uncaria; sometimes adding herbs to nourish the liver, see below).  Silkworm is also used in severe cases of wind-phlegm.  Many patients with senile dementia have neurological problems that correspond to the wind-phlegm syndrome.
However, gastrodia is sometimes used in formulas for senile dementia based on the theory that internal wind agitates the mental functions even if there is no physical manifestation of wind as movement.   The consideration is described by Peng Jin at the Institute of TCM Basic Theories (8):
The liver responds to moistness and is averse to dryness.  Moistness makes the liver soft which ensures a normal mental activity.  The aged people with prolonged illness are susceptible to deficiency with consumption of the yin essence.  Deficiency of the liver yin may result in restlessness of the mind due to stirring-up of the endogenous wind, hence the appearance of unconscious shaking of the head, foreign body sensation in the eye, tinnitus, sleeplessness, and irritability.
In such cases, the liver is nourished with herbs such as rehmannia, cornus, ho-shou-wu, and lycium, while gastrodia is added to calm the wind.  Gastrodia is also used in the context of modern theories that atherosclerosis, a syndrome of blood stasis and phlegm accumulation, leads to hypertension and mental deficits from poor blood circulation.  Gastrodia helps alleviate the hypertension while other herbs used along with it address the blood stasis syndrome (e.g., salvia, red peony, cnidium) and the phlegm accumulation syndrome (e.g., pinellia, citrus, arisaema, bamboo).
SUMMARY OF THE MODERN MEDICAL REPORTS
The approach of differential diagnosis and corresponding treatment is a dominant theme in Chinese publications about resolving senile dementia.  This is because the disease is thought to arise gradually from constitutional disorders rather than from some specific dysfunction in the brain.  This interpretation differs markedly from the modern medical approach to Alzheimer’s disease, a main cause of senile dementia, in which researchers examine specific proteins that are accumulating in the brain and deficits in specific neurotransmitter substances in hopes of finding a successful treatment that is not dependent on the whole body functions.  In virtually all Chinese reports, the importance of tonification therapy was emphasized.
Despite the stated reliance on differential diagnosis, almost every modern herbal prescription designed specifically for treating senile dementia (or other brain/mind disorders that have overlapping characteristics) includes one or more of the following limited list of herbal ingredients: acorus, polygala, curcuma, arisaema.  These are all herbs that treat the “phlegm-mist” disorder.  It can be implied that the basic Chinese approach is comprised of these methods:
·       Treat the constitutional organ-system disorders, mainly deficiencies, that can cause numerous symptoms and diseases;
·       Add the herbs that are specific for brain disorders, which are a small number of phlegm-mist resolving agents; and
·       Incorporate a blood-stasis treatment relying primarily on this short list: salvia, red peony, pueraria (this indication based on modern research), persica, carthamus, and cnidium.
REFERENCES
1.     Fruehauf H, Treatment of Difficult and Recalcitrant Diseases with Chinese Herbs, 1997 Institute for Traditional Medicine, Portland, OR.
2.     Hong-Yen Hsu, et al., Oriental Materia Medica: A Concise Guide, 1986 Oriental Healing Arts Institute, Long Beach, CA.
3.     Huang Bingshan and Wang Yuxia, Thousand Formulas and Thousand Herbs of Traditional Chinese Medicine, vol. 2, 1993 Heilongjiang Education Press, Harbin.
4.     Chun-Han Zhu, Clinical Handbook of Chinese Prepared Medicines, 1989 Paradigm Publications, Brookline, MA.
5.     Wang Xiaoping and Zhai Mudong, Experience in TCM treatment of senile dementia, Journal of Traditional Chinese Medicine 1996; 16(4): 299–303.
6.     Sun Guanlan, Ren Jianlin, and Sun Qingjun, Advances in TCM treatment of senile dementia, Journal of Traditional Chinese Medicine 1999; 19(4): 304–312.
7.     Wang Dehua, Huang Xia, and Du Shuhua, A clinical trial on Yu Cong Tang in treatment of senile dementia, Journal of Traditional Chinese Medicine 1999; 19(1): 32–38.
8.     Peng Jin, Professor Kong Lingxu’s experience in TCM treatment of insomnia, Journal of Traditional Chinese Medicine 1999; 19(3): 175–181.
APPENDIX: Reference Formulas
In the two review articles about treating dementia (5, 6), several traditional formulas were mentioned that are commonly used; the ingredients are presented here for easy reference. A few formulas are not included here because they are well known (e.g., Xiaoyao San, Guipi Tang) or because they are not described in any of the standard literature sources devoted to Chinese herbal formulas.
Kidney-nourishing Formulas
A pair of formulas that are used by some doctors are the Zuogui Wan (Left Returning Pill) and Yougui Wan (Right Returning Pill).  The formula names refer to the idea that the left kidney houses the yin and the right kidney houses the yang.  The formulas have five herbs in common, and these five ingredients mainly nourish the yin and restrain the essence.  A formula similar to Yougui Wan, Dihuang Yinzi, includes altaica (used as a type of acorus) and polygala (not listed below); the formula is often prescribed for neurological disorders.

Zuogui Wan
Yougui Wan
Dihuang Yinzi
Rehmannia
Rehmannia
Rehmannia
Dioscorea
Dioscorea
Hoelen
Cornus
Cornus
Cornus
Lycium
Lycium
Ophiopogon
Cuscuta
Cuscuta
Morinda
Antler gelatin
Aconite
Aconite
Cyathula
Cinnamon bark
Cinnamon bark

Tang-kuei
Cistanche

Deer antler
Schizandra

Eucommia
Dendrobium
Phlegm-resolving Formulas
Erchen Tang is the base formula for the warm the gallbladder (wendan) formulas; it improves the function of the stomach and spleen to prevent accumulation of phlegm and helps dry most phlegm.  By adding the cooling herbs bamboo and chih-shih, the formula drains hot phlegm.  Coptis can be added to further clear heat and also to dry dampness.  Although the formula names indicate a warming action for the gallbladder, the meaning is that the prescription aids the gallbladder in discharging bile.  The bile carries out heat and phlegm, with its downward purging action. 

Erchen Tang
Wendan Tang
Huanglian Wendan Tang
Pinellia
Pinellia
Pinellia
Citrus
Citrus
Citrus
Hoelen
Hoelen
Hoelen
Licorice
Licorice
Licorice

Bamboo
Bamboo

Chih-shih
Chih-shih


Coptis

Gastrodia Formulas 
There are two commonly-mentioned gastrodia formulas, one for treating a wind-phlegm disorder originating with spleen-qi deficiency (Banxia Baizhu Tianma Tang), and the other for treating a wind-fire disorder that arises from liver-yin deficiency (Tianma Gouteng Yin).

Banxia Baizhu Tianma Tang
Tianma Gouteng Yin
Pinellia
Gardenia
Citrus
Scute
Atractylodes
Cyathula
Hoelen
Eucommia
Licorice
Leonurus
Gastrodia
Loranthus

Polygonum stem

Hoelen

Haliotis

Uncaria

Gastrodia
Blood-vitalizing Formulas
There are numerous traditional blood-vitalizing prescriptions to choose from, all of them having similar constituents and actions.  In modern practice, salvia is often added.

Tongqiao Huoxue Tang
Fuyuan Huoxue Tang
Tao Hong Siwu Tang
Buyang Huanwu Tang
Xuefu Zhuyu Tang
Persica
Persica
Persica
Persica
Persica
Carthamus
Carthamus
Carthamus
Carthamus
Carthamus
Red peony
Rhubarb
Peony
Red peony
Red peony
Cnidium
Trichosanthes root
Cnidium
Cnidium
Cnidium
Allium
Tang-kuei
Tang-kuei
Tang-kuei
Tang-kuei
Jujube
Pangolin scale
Rehmannia
Astragalus
Rehmannia
Musk
Bupleurum

Earthworm
Bupleurum

Licorice


Licorice




Chih-ko




Achyranthes




Platycodon

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