Treatment of adult ADHD in Traditional Chinese Medicine with Classical Ben Shen Diagnosis
Published in Acupuncture Today April 2022 and May 2022 issues
by Isabella Gucci-Ruffalo and Joseph Changqing Yang
ADHD
Attention deficit hyperactivity disorder is characterized by an ongoing pattern of inattention, hyperactivity, unfocused motor activity and impulsivity that interferes with functioning or development, according to the National Institute of Mental Health. It is often diagnosed in childhood and lasts into adulthood. ADHD is a chronic condition that can have a serious and long-lasting impact on a person's life. While there is no cure for ADHD, it is possible to reduce symptomatology with the currently available treatments, which include medication, psychotherapy, training, or a combination approach.
Case Presentation
A 30-year-old female patient presents with ADHD which was diagnosed in childhood. She reports frequent procrastination, inattentiveness, and inability to focus. The patient reports that she has difficulty processing one thing at a time and prioritizing tasks. She makes careless mistakes often because of this. She complains of poor short term memory recall and needs to write things down or else she will forget. Only creative work seems to summon her focus. She also complains of emotional dysregulation and occasional irritability, which manifests as a clogged sensation in the throat, palpitations, and a rising sensation of energy. She also reports social anxiety, hypersensitivity to sounds and stimuli, vivid dreams, and occasional night sweats.
Her medical history includes asthma since early childhood, and she has secondary complaints of sinus congestion, fatigue, nausea, occasional bloating and constipation. Most significantly, the patient has a history of trauma at age 11 which was left unresolved for ten years until she began psychotherapy. She self-medicated with CBD extract but declined all psychiatric medication until 2 weeks ago when she started Provigil (Modafinil), a medication that promotes wakefulness. This medication is thought to work by altering the natural chemicals (neurotransmitters) in the brain, according to Drugs.com. Since starting this prescription, the patient complains of the side effects of this medication which include lowered appetite, nervousness, and increased body temperature.
The patient’s physical presentation is robust. She presents with moderate bodily activity and weighs 298 lbs. at 6 feet tall. She has a clear, high-toned voice and makes eye contact; she does not appear as a mentally deficient constitution from a Classical Chinese Medicine perspective. She has a very present demeanor and an easygoing attitude during her treatments with us. However, when discussing her personal history of trauma, her voice tends to become relatively quiet, and her facial emotions flatten.
Using TCM diagnosis, the patient’s tongue presents is pink, swollen, and geographic with deep midline and horizontal cracks, and a dry coat. Her pulses are rapid overall and deep in the chi positions. Her left pulses are weak and thready in the cun and guan positions, and her right pulses are forceful, and slippery in the guan position.
TCM diagnosis
Shen evaluation according to Classical Ben Shen diagnosis is a three level diagnostic system. It is comprised of癫狂 Dian kuang pattern differentiation, 神气Shen qi pattern differentiation and 五神 Five Shen pattern differentiation. These diagnostics patterns are based on Nei Jing Inner Classics and several classical texts. This is the major diagnostic system for mental disorders in Classical Chinese Medicine, and it is entirely rooted in the foundational texts that Chinese Medicine is founded upon.
Mental evaluation:
The first level is a mild yin pattern or ‘Dian’ disorder.
The second level is Shen Qi Irritability.
The third level is the Heart Shen Irritability.
Physical evaluation:
Heart fire, Spleen qi deficiency with damp phlegm obstruction.
Treatment principle:
Stabilize Shen qi, calm Heart Shen, clear the Heart fire and transform damp phlegm.
Case Analysis
From a Traditional Chinese Medicine (TCM) point of view, the patient has clear signs of the Heart not storing the Shen causing the Shen to ‘float’, which manifests as ADHD symptoms. In addition, she has moodiness and irritability also to the Heart Shen dysregulation. She is also suffering the medication’s side effects, which weakens her Shen and mental energy further.
After the Shen evaluation, we evaluated her mental energy pattern with the three level diagnosis following the Classical Ben Shen (本神) system. According to out diagnosis system, the mental energy pattern of Shen qi is the core concept for all mental disorders. The first level diagnosis is of a mild yin pattern or ‘Dian’ disorder, the second level is Shen qi irritability, and the third level is Heart Shen irritability. Our treatment focuses on this main mental energy pattern, though she also falls into the diagnostic pattern of Shen qi oversensitivity secondarily. Her TCM zang fu organ pattern is Heart fire with Spleen qi deficiency and damp phlegm obstruction; her body weight, nasal congestion, and clogged sensation in the throat are all signs of damp phlegm accumulation in her body.
Treatment protocol
First visit (07/20/2021):
We began the first treatment after the initial mental and physical evaluations at her first visit. Acupuncture treatments require mental Shen preparation, which we do with Shen communication techniques to guide the patient’s Shen when we are performing acupuncture treatment. The techniques used are based on the patient’s Shen Qi pattern and the four levels of examination.
Acupuncture Points:
DU20, REN22, REN12, REN4, ST40, SHEN GUAN, KID4, HT5, SP4, GB13, LV3, GB40
Herbal Formula:
Bi Yan Pian 8 pills 3x/day
Shen Ling Bai Zhu Pian 8pills 3x/day
Nutrition & Lifestyle Recommendations:
We advised the patient to eat at regular mealtimes, incorporate spleen tonifying foods, and eliminate dairy, ice, processed foods, and refined sugars. We taught and prescribed her Medical Qi Gong exercises and meditation.
Second visit (07/26/2021):
Patient reports that her symptoms have improved. Within an hour after the last treatment, she released many repressed tears and experienced lightness and relief from this release. She reports feeling more ‘dialled in’, focused and settled since last week and experiences increased motivation. Due to the medication, she has almost no hunger, increased body temperature, and sweating. She is on day 2 of her menstruation and feels slightly irritable. She mentions her throat can feel stuck when she gets anxious. She enjoys her new nutritional and lifestyle habits and attributes better digestion and respiration to these changes. Her tongue and pulse remain unchanged since her first treatment.
Acupuncture Points
DU20, REN22, REN12, REN4, ST40, SHEN GUAN, KID4, HT5, SP4, GB13
Third treatment (08/02/2021):
The patient reports improvement and that she felt ‘great’ after last treatment. Today only she feels slightly more ‘stuck’, as she just got offered a new job position and is unsure whether to take it. She feels frozen towards making the decision and slightly anxious about it. Her stools are looser than usual but still somewhat formed. She is tired and feels that her body is holding the stress. Her eyes are dry due to the medication.
Acupuncture Points
DU20, REN22, REN12, REN4, ST40, SHEN GUAN, KID4, HT5, SP4, GB13, LV3, GB40
Herbal Formula:
Bi Yan Pian 8 pills 3x/day
Shen Ling Bai Zhu Pian 8pills 3x/day
Fourth treatment (08/16/2021):
Patient reports feeling better, she feels more focused and able to prioritize things and does tasks more quickly throughout the day than before. Since she ran out of the herbal prescription, she notices some more sinus congestion and slower digestion and asked us to refill herbs as they were very effective in sustaining her results. She decided to take the new part time job. At her current job, she discovered some undesirable news and became irritable about it. She managed to catch herself almost immediately and decided to choose to feel calm about it instead. She said she had never self-regulated like this before and she was pleased to feel calmer and in control of her emotions.
Acupuncture Points
DU20, REN22, REN12, REN4, REN5, ST40, SHEN GUAN, KID4, HT5, SP4, GB13, LV3, GB40
Herbal Formula:
Bi Yan Pian 8 pills 3x/day
Shen Ling Bai Zhu Pian 8pills 3x/day
Fifth treatment:
The patient reports feeling calmer and more ‘grounded’ than ever and more able to focus on tasks. She is prioritizing better and feels her motivation has been stable. She reports that her PMS this month is much milder than usual. She mentions that recently her sleep has been deeper than normal and that it is difficult for her to wake up in the morning. She thinks this is due to the medication over-stimulating her and burning her out, leaving her exhausted by the end of the day. She started a second part time job this week, and she is still getting acclimated but feels positive about it.
We added a custom herbal prescription on her fifth treatment, which is indicated both to calm her Shen and transform the damp phlegm. This is a customized formula that has been combined according to the Ben Shen mental health theories and principles.
Acupuncture Points
DU20, REN22, REN12, REN4, REN5, ST40, SHEN GUAN, KID4, HT5, SP4, GB13, LV3, GB40
Herbal Formula
Long Gu 25g, Shi Jue Ming 15g, Fu Shen 15g, Chen Pi 12g, Shi Chang Pu 12g, Zhi Ban Xia 12g, Bai Zhu 12g, Zhi Zi 9g, Sha Ren 9g, Mu Xiang 9g
Sixth treatment & Summary:
Acupuncture Points
DU20, DU23, REN12, REN4, REN5, ST40, SHEN GUAN, KID4, KID3, KID7, HT5, SP4, GB13, LV3
Herbal Formula: continued the custom prescription.
The patient’s ADHD symptoms continue to improve. She reports feeling more grounded, focused and attentive. She feels significantly less irritable, and emotionally lighter after having let go of many harbored emotions throughout the course of this treatment. She experiences improved motivation, and she is eating healthier, meditating more regularly and managing her tasks more effectively. Her ‘dian’ disorder has improved and her Shen qi mental energy is much more regulated.
The patient discontinued use of her ADHD medication two weeks ago much to our surprise. She experienced some fatigue with the withdrawal. We have continued her treatments since completing this study, and she reports continued improvement in her symptoms and good quality sleep. She reports that her nasal congestion and digestive function is significantly improved and ‘normal’ now, and she only experiences discomfort when she eats dairy or forgets to take her herbal prescription. She is pleased with the improvement of her condition, and now that she feels more emotionally and physically regulated, she intends to prepare her body for pregnancy in the near future.
Commentary & Conclusion
It must be noted that this patient is not just a psychiatric ADHD patient, but that she also experiences dysregulation on the physical and energetic levels. The all-encompassing nature of Chinese Medicine can be used to treat her holistically, by considering her physiology and her personal history to create effective treatment that includes traditional lifestyle support as an important adjunct to her psychological treatment.
Based on this classical system, we treat the root of imbalance (Shen disharmony) to address the branch symptomatology (ADHD, the chemical imbalance triggered by the Shen disharmony). While modern psychiatry is a tool for addressing the mental level, real healing takes place on all levels of the human being that are simultaneously part of the disharmony. This is where the patient-oriented approach the time-tested efficacy of Classical Chinese Medicine can be of great value in the clinic.
After six consecutive acupuncture and herbal medicine treatments, our patient’s mental energy, i.e., Shen qi is regulated. Her Heart Shen is ‘returning to its house’ in Traditional Chinese Medical terms. In TCM, the Shen is the psyche, mind, spirit and monarchy of our life and qi is the root of life, thus Shen qi is the energy of our life and psychospiritual state. We have achieved great results with our diagnosis and treatment system based on this traditional philosophy and wisdom. The results indicate that the Ben Shen (本神) concept and theory from the Inner Classics (内经) have significant implications for the treatment of mental health with Traditional Chinese Medicine.