Shen-Zhi Theory: Analysis of the Signs and Symptoms of Mental Disorder
Qu Lifang and Mary Garvey
The Huangdi Neijing (Yellow Emperor’s Inner Canon) contains numerous references to ‘spirits’ that are said to reside within the body. The term ‘shen-zhi’ means ‘spirit-mind’ and telescopes the five spirits (shen, hun, po, yi, zhi) of early Chinese medical theorising. Shen-zhi theory explains the principles for understanding Chinese medicine’s perspective on human consciousness. The theory describes how each of the wu shen (five spirits) govern certain aspects of mentality and are closely related to sensory faculties, body tissues, visceral systems, and physiological substances according to the wu xing (five phase) framework of correspondence and relationship. Spirit activities thereby provide the human organism with its distinctive array of mental and sensory abilities including intelligence, insight, focused attention and memory. Shen-zhi theory is derived from key sections of the Neijing that define the nature of the wu shen, their physiological activities and relationships. When these resources and relationships are disrupted a variety of common or more serious disorders may result. We discuss some of these, and a number of specific disorders that have a particular connection with the five spirits and shen-zhi theory. Broadly speaking, they are ‘mind’ or ‘mental’ disorders. Analysis of their signs and symptoms illustrates the theory and clarifies its diagnostic relevance for modern clinicians.
Introduction Despite the enormous differences in time and perspective the traditional Chinese medicine (TCM) practitioner can analyse and interpret the signs and symptoms of mental disorder as they appear in the Chinese medical classics and in today’s modern clinics by using frameworks such as shen-zhi theory. The TCM view of mentality and mental disorders does overlap with modern western psychological and psychiatric parameters, to some degree. Instances where the Chinese medical perspective does not correspond with modern medical and psychiatric nosologies however are not uncommon.
For example, the term xiao ke ( dispersion-thirst) was first mentioned in the Jingui Yaolue (Essential Prescriptions of the Golden Cabinet) and is often suggested as an equivalent TCM disease name for diabetes. But while xiao ke includes diabetes, it is in fact a much broader disease category. For the purpose of our discussion, we also note that the xiao ke patient experiences a loss of jing (essence) because of the kidney’s ‘failing to hold’. Diabetic polyuria, a symptom of kidney failing to hold, exacerbates jing loss and sensation disorders such as peripheral neuritis, numbness, or feeling like they are wearing a glove or sock are common. Clearly xiao ke, depleted jing, diabetes, polyuria and peripheral neuritis are not symptoms of mental disorder. But Chinese medicine’s view of human consciousness includes the reception and interpretation of sensory information; and TCM physiology emphasises the functional links between its visceral systems and their associated substances, tissues, sense organs, – and spirits. As we will see, disordered sensations such as diabetic neuropathy demonstrate the po-jing (physiological) relationship and resultant shen-po (mental-sensory) disharmony. (Explanations for these terms and relationships are given below.)
Areas of theoretical disparity between traditional Chinese and modern western medicines provide a point of interest and challenge for clinicians today. Furthermore, very early Chinese conceptualisations of mentality and psychology permeate its medical tradition and persist to the present. Rather than a Cartesian separation of the physical and mental, Chinese philosophy emphasises the ‘one qi running through heaven and earth’ (Zhuangzi 22, cited in Zhang, 2002: 49), and Chinese medicine assumes an integrated body-mind. Which is not to say that classical Chinese literature does not discuss the mind.
Information from the classical literature is examined to explain Chinese medicine’s perspective on mentality, its development and resources, and to confirm the meaning of relevant terms and relations. Five key features of spirit-mentality are set out in the Lingshu Benshen (chapter 8 of the Huangdi Neijing, Lingshu – the Yellow Emperor’s Inner Canon, Spiritual Axis). This provides the origin and basis of shen-zhi theory. The final section of the paper will use the shen-zhi model presented in Lingshu Benshen to discuss and interpret some of the clinical presentations that signal disordered mental function. Signs and symptoms of mental disorder illustrate the discussion and identify key factors for differentiation according to TCM diagnostic protocols.
Section 1: Human consciousness According to Zhang Dainian the most detailed discussion of the mind in Chinese literature before the Qin Dynasty can be found in the Xunzi.
Xunzi 22, On the rectification of Terms: The mind gives meaning to impressions. (Cited in Zhang, 2002: 395)
The Xunzi goes on to say that the mind encounters the outside world directly via the five senses and its ‘impressions’ include its ability to recognise and assess the information we perceive. But, what is the ‘mind’, and how do the ancients explain these abilities?
In early Chinese medical literature philosophical concepts such as yin-yang (were adopted and elucidate a fundamental shift towards incorporating the newly burgeoning naturalist perspectives. A number of key terms are relevant for this discussion.
During the Warring States period, things that were most pure or quintessential ‘were considered [ jing-essence], be they offerings presented to external spirits or the potency of the spirits themselves’. Then, from around the 4th century onwards, medical-physiological theories were formulated ‘which fused the physical and spiritual components of the human organism, and which made [ qi] the source of each’. (Harper, 1998:119)
At conception, female and male jing-essence combine to form the new life. The ovum and sperm provide yuan jing (original, or congenital essence) and yuan shen ( original spirit) for the new life. Yuan jing and yuan shen are the new individual’s pre-heavenly ‘life material’ and ‘life energy’.
This idea is first presented in the following two lines of the Neijing Lingshu:
Lingshu Benshen, lines 21 and 22 sheng zhi lai wei zhi jing, liang jing xiang bo wei zhi shen. Life [its coming forth and evolution] indicates jing [essence], when the two jing [yin-yang, egg-sperm] combine this indicates shen [spirit].
The Huangdi Neijing (Yellow Emperor’s Inner Canon) itself does not differentiate between pre- and post-heavenly shen. Neijing terminology uses only ‘shen’. It is not until the Song Dynasty that the difference between pre- and post-heavenly (pre- and post-natal) shen is discussed in the literature. After birth, pre-heavenly resources are stored in ming men and the kidneys, and Li Shizhen (Tang Dynasty) says that yuan shen is stored in the brain.
Daoist meditators place great importance on yuan shen as ‘spiritual consciousness’. Because it exists before birth it is thought to be part of the qi that pervades the whole universe. Si shen on the other hand is ‘ordinary consciousness’ and consists of the senses, feelings, thoughts and perceptions we experience during our lifetime. (See Kohn, 1989 & Robinet, 1997)
At conception the new life comprises the inherited or pre-heavenly yuan jing and yuan shen: these provide the foetus with basic developmental resources, information, and instinctual functions. Unlike our acquired or post-heavenly resources, yuan shen is undifferentiated life energy: there is no cognition, memory or analysis as such, none of the sophistication of the post-natal human psyche.
Post-heavenly creation is the myriad beings of Laozi, chapter 42: human life and the 10,000 things arise at the intersection of heaven and earth. For human life, conception is the primary example of the meeting of heaven and earth, the essential yang and yin. ‘At the level of the symbolic meaning of Three [Heaven-Humanity-Earth], we have life, the living, the vital thrust sheng’ (Larre et al, 1995: 23, commenting on Benshen, line 21 above).
The san bao ( three treasures) or jing-qi-shen triad refers to this stage or level of pre-natal resources. Our life resources develop and differentiate from them and according to wu xing ( five phase) manifestations. Post-heavenly wu shen ( five spirits) differentiation mirrors the generation of the wu zang ( five viscera) – Chinese medicine’s internal organ systems. The wu shen therefore represent the differentiated post-natal spiritual resources that arise from an undifferentiated yuan shen.
In modern TCM texts, shen () is translated as ‘spirit’ and in a broad sense refers to post-natal life activities. More specifically, the post-natal heart-shen governs human intelligence: it makes us awake, alert and responsive during the day. At night it becomes inactive and returns to its lodging in the heart. The heart-shen is linked with human consciousness, and importantly for TCM, the term incorporates physical and mental activities. Its function in healthy physiological and mental activities can be observed in the body’s external manifestations, such as healthy complexion, bright eyes, physical agility, and coherent speech.
Shen-zhi () is another name for the spirit or ‘spirit-mind’ (Wiseman & Feng, 1998: 551). The term implies the wu shen: the shen hun po yi zhi are the ‘spirit’, ‘ethereal soul’, ‘animal soul’, ‘ideation’, and ‘mind’ (Wiseman & Feng, 1998: 207). ‘Shen-zhi’ is made up of the first and last serving to telescope all five spirit resources. Lines 21 and 22 of Lingshu Benshen provide the basis of shen-zhi theory by setting out that life activities, with respect to wu shen physiology and mentality, are based on jing-essence.
Section 2: Lingshu Benshen Chapter 8 of the Neijing Lingshu is titled Benshen ( The basis/root is spirit). It expounds the psychological aspects of the visceral systems presented in chapter 8 of the Neijing Suwen (entitled Ling lan mi dian lunThe Secret Treatise of the Royal Library).
Benshen lines 21 to 30 are of particular interest for shen-zhi theory. The passage deals with the wu shen, the five spirits that produce and are responsible for various facets of the human psyche. Orderly, integrated wu shen activities perceive and analyse sensory information; their interdependent functions create human consciousness, intelligence, and cognitive ability.
The number five signals that wu xing systematic correspondence provides the theoretical underpinning, and that all its relational qualities apply. The normal course of shen-zhi activities therefore requires, includes, and depends on the close relationships between the wu shen and with their respective wu zang, wu guan ( five offices or sense organs), and wu ti ( five body tissues). These relationships are essential for understanding the pathogenic mechanisms and interpreting the signs and symptoms of mind disorder.
All five systems provide specific kinds of sensory information. The heart-shen governs the tongue and transmits language information. This is why speaking can relieve pressure on the heart and talking with friends can be recommended therapeutically. The spleen-yi transmits taste information, the kidney-zhi transmits aural information, and the lung-po transmits tactile and olfactory information. The liver opens to the eyes so the hun participates in sight and the transmission of visual information. Because it governs the sinews and the movement of joints, the liver-hun also transmits sensory information regarding movement, balance and proprioception.
Lingshu Benshen line 25: suo yi ren wu zhe wei zhi xin. when something takes charge of the myriad things, this indicates xin [heart].
The human organism perceives and responds to the external world every waking moment via a steady stream of sensory information, and according to line 25, all external matters and perceptions are received and co-ordinated by the heart-shen. The information includes not only received information, but also how we perceive, recognise, process, and interpret that information.
Lingshu Benshen line 26: xin you suo yi wei zhi yi. when xin applies itself this indicates yi [ideation].
The term ‘yi’ invokes a range of interpretations such as attention, intent, ideation; and spleen-yi governs thinking, memory and recollection. So when the heart-shen applies itself to reception and co-ordination, it is supplied by the spleen-yi’sattention to and analysis of the information received by the five senses.
At the level of human mentality, the heart and spleen relationship works to process perceptions; the spleen-yi contributing focussed attention and recollection of information. Their harmonious interaction produces immediate, first-stage analysis and assessment.
Lingshu Benshen line 27: yi zhi suo cun wei zhi zhi. when yi can manage the myriad things this indicates zhi [mind].
In line 27 the spiritual resource associated with the kidney zang has an all-encompassing and somewhat conclusive role: the results of perception, ideation and mental processing are taken up by the kidney and called ‘zhi’.
English translations of zhi again indicate a multi-layered concept – ‘mind’, ‘memory’, ‘power of concentration’, ‘will’, ‘direction’ and ‘determination’ (Larre et al, 1995: 16; Wiseman & Feng, 1998: 395; Wu, 1993: 39; Wu & Wu, 1997: 542); and the kidney system itself evokes a sense of power and permanence. Kidney-zhi functions provide a breadth and depth of understanding that give the human organism the potential to reach levels of wisdom and intelligence. ‘Will’ and ‘determination’ are both dependent on kidney jing, and provide zhi xiang ( ideals and ambition).
Kidney feng cang ( seal store) function preserves the quintessential: physiologically this is jing, and for human consciousness it is long-term memory. Thus it would appear that the heart, spleen and kidney all contribute to memory – shen for reception, yi for processing, and zhi for storage of information. It seems appropriate that the faculty of memory should be cared for by the three post-heavenly systems most closely associated with ancestral resources.
Suwen, chapter 8 says that skill also comes from the kidney. In the context of human mentality, skill is related to wisdom, but in Chinese medicine the idea includes physical skill as well. This is why any skilled achievements, whether those of a pianist, gymnast, or doctor, are a reflection of the person’s kidney-zhi. It is kidney-zhi that provides determination and concentrates the mind and the jing.
According to Lingshu Benshen the heart-shen receives and co-ordinates all our perceptions, responses and cognitive processes. Together the heart-shen and spleen-yi perform the initial processing of sensory information to accomplish first-stage analysis and assessment. Whilst yi-shen deals with initial ideas and first-stage analysis, the kidney-zhi refers to deeper conclusions and the more refined results of cognitive processing, and zhi-shen to these being stored in the kidney. The kidney-zhi and heart-shen relationship therefore enables more sophisticated processing and depth of understanding.
The symmetry of content in the 8th chapters of Suwen and Lingshu suggest the connection and so far, the spiritual resources discussed in Benshen mirror the physiology of their visceral systems in chapter 8 of the Suwen. The spleen’s yun hua () function provides first-stage digestion or processing, involving the ‘movement and transformation’ of raw substances taken into the body. Kidney qi hua () second-stage ‘qi transformations’ involve pure qi and jing substances, and feng cang the storage and protection of them.
The heart-spleen-kidney/shen-yi-zhi spirit functions are presented in Lingshu Benshen lines 25-27. These few lines show some of the links and relationships that contribute to the complex processes involved in sensory perception, analysis, consciousness and cognition. It is the nature of shen-zhi activity that these processes are accomplished instantly.
Life emerges through the interaction of heaven and earth, yang and yin. Our pre-natal resources are embodied post-natally by the jing-qi-shen triad, and the full energetic configurations of post-natal human life manifest in accordance with wu xing systems. Pre-heavenly jing and shen form the basis of post-heavenly manifestations and produce the body form.
Section 3: Body-mind In a passage that echoes Lingshu Benshen (lines 21-22), the Taisu refers specifically to the body form, its development and relationship with jing and shen.
When the two spiritual forces [male and female jing-shen ] conjugate, they unite to shape a physical form [xing ]. They [thus] always come into being before the body [of the offspring, for they provide its initial endowment of vitality as well as its form]. This is called ching [jing ]. (cited in Sivin, 1987: 149).
Certainly for Chinese medical thinking, physicality and mentality are not just closely linked: the body form ( xing) is the house of the shen and shen governs the body form. When xing-shen are unified the functional activities of the wu shen manifest externally through the wu zang, wu guan and wu ti. Disintegration occurring in any of the relationships between the wu shen, and with their respective zang, guan and ti can disrupt human life and consciousness.
Furthermore, chapter 23 of the Suwen states that the wu shen are ‘stored’ in their associated zang. Lines 100-120 of Lingshu Benshen link this with zang physiology and storage of vital substances. For example, in line 100: ‘The liver stores the blood, and the hun adheres to the blood.’
Heart stores the shen Suwen, ling lan mi dian lun xin wei jun zhu zhi yi, shen ming chu yan. heart holds the office of supreme commander, shen ming [spirit light] stems from it.
The Suwen states that the heart-shen plays the leading role in consciousness and controls the proper functioning of our mental activities. If there is disruption with any aspect or at any stage of the wu shen activities (and their zang-guan-ti interactions) this can influence the heart, shen, and shen ming ( spirit light).
In TCM the heart opens to the tongue, governs the blood and vessels, and heart blood holds the shen. Normal heart-shen functioning ensures consciousness and cognition are healthy and ordered. Consequently the five shen, zang, guan, ti, and shen-ming function harmoniously, and body-mind activities are responsive and apposite.
Laughing is a heart sound and the heart governs the act of speaking. When spoken and emotional communication are lucid and appropriate we know what we should or should not do or say, when to laugh and when not to. Social, behavioural and communication skills therefore provide a clear indication of the healthy heart-shen maintaining orderly spirit and mental faculties.
Disordered shen ming and heart-shen are observable in the complexion and eyes, and the person may experience disturbances involving speech, consciousness, inappropriate moods and laughter. Clinical manifestations indicating shen disturbance include dyslogia, aphasia, or incoherent speech, coma, psychosis, mania, or delirium.
Liver stores the hun The liver governs the sinews, opens to the eyes, stores the blood and liver blood holds the hun. Therefore the liver-hun participates in the perception of visual information and in the movement and function of the joints. The Lingshu establishes another important relationship between the hun and the shen:
Lingshu Benshen line 23: sui shen wang lai zhe wei zhi hun That which faithfully follows the shen going and coming indicates hun.
Wang lai ( going and coming) applies to the communication between internal (mind-body) and external (out-of-body) environs, which is accomplished by the heart-shen and liver-hun. This is an area of subtle energetic exchange and relationship that depends on the shen-hun’s ability to move freely between the two. Their relationship and movement is supported by a peaceful mind, nourished by the liver and heart blood, and disturbed by agitation, emotional upset, pathogenic heat, or depleted physiological resources. The coming and going of the shen and hun therefore is a physiological state.
Visual perception is an important aspect of shen-hun interaction and one that exemplifies their relationship and movement – ‘going and coming.’ When the shen wants to look at something, the hun follows and focuses immediately on the object of attention. The heart-shen receives visual information via the liver-hun-eyes, engages recall, and ascertains meaning.
If the hun fails to follow the shen, a person’s xing-shen is no longer unified. Their eyes are blank because the liver-hun cannot correctly transmit what it is seeing to the heart-shen, or the heart-shen cannot assess the matters being perceived by the hun-eyes. This is why in Chinese medicine we say that the liver stores blood, liver-blood nourishes the eyes and houses the hun, heart-blood houses the shen, and the shen and hun must always follow each other.
When the shen-hun are orderly and harmonious, their coming and going is swift and light, barely registering in our conscious mind. Shen-hun activity and relationship allow human consciousness to realise the kind of understanding that comes from this subtle connectedness. Larre and Rochat de la Vallée (1995: 39) call this ‘spiritual intelligence’ – a kind of mental faculty that might also be called ‘insight’, or ‘perspicacity’ – and remind us that (especially in chapter 2 of the Zhuangzi) the hun often makes these connections and relationships during sleep.
Lung stores the po According to the Neijing the lung stores the po, opens to the nose, and corresponds to the skin and body hair. The lung-po therefore participates in perceiving sensations and information via the nose and skin. The po is sensitive to the environment around the body, registering cold and heat, and helping us to avoid danger. Healthy lung-po activity gives us robustness, responsiveness and agility (Cheng, 1988).
In contrast to the hun, this is a more corporeal faculty. As well as sensitising the body, the po enables physical movement, especially involuntary and instinctual movements and reactions. For example, the po is thought to be responsible for a newborn baby’s ability to cry and take milk; and bodily cycles and rhythms such as respiration animate the body and are governed by the lung-po. (Larre, 1995: 38; Wiseman and Feng: 180)
It is said that the hun and po begin to function at birth. A set of contrasting features create balance and symmetry between them: the yang and the yin souls, the ethereal and corporeal, their relationships with blood and qi, the shen and the jing respectively. The po is closely associated with the jing.
Lingshu Benshen, line 24: bing jing er chu ru zhe wei zhi po That which associates with the jing in their exiting and entering indicates po.
‘Exiting and entering’ () suggests parallels with the shen-hun activities, but as we might expect from the more substantial jing and more corporeal po, ‘chu ru’ refers to more concrete survival issues and the physicality of life. ‘The first of the exits is the exit into the world [birth]... Conversely, the last of the entrances – burial, the return to earth – is death.’ (Larre et al, 1995: 40)
With the first breath the lung-po becomes active, and when we die the po leaves the body via the anus and returns to the earth. From birth and until the end of our physical existence, the po-jing relationship sees to the day-to-day direction and maintenance of life that requires taking in nourishment and rejecting waste – inspiration and expiration, assimilation and excretion.
Depleted jing can disrupt the lung-po, and compromise jing-po exiting-entering functions; shen-po mental-sensory activities may also become disordered. The account of xiao ke and diabetic neuropathy above illustrates the physiological relationships and sensory disruptions. Once there is shen-po disharmony, signs and symptoms will include disordered or abnormal sensations. Anosmia, olfactory or tactile hypersensitivity, dysaesthesia, skin paraesthesia, and olfactory hallucinations are examples. Depleted jing also affects the po’s role in physical movement so that, unfortunately, falls are common in the elderly as they lose their strength and dexterity.
Spleen stores the yi Spleen-yi is the mental faculty that deals with the products of sensation and perception, focussing and forming ideas. Essential to heart-shen processing of sensory and perceived information is its relationship with spleen-yi’s recalled experience and knowledge.
Lingshu Benshen line 103: pi cang ying, ying she yi. The spleen stores the ying and ying lodges the yi.
Shen-yi reflection and analysis processes depend on the spleen’s production and storage of ying ( construction [qi]). When we are tired and hungry our ying qi is weakened and this causes our thinking to become muddled and slow. Similarly, the reason a patient with heart blood and spleen qi vacuity complains of slow-thinking and poor memory is that their ying-xue ( construction and blood) is depleted.
In cases of acute blood-loss the spleen can no longer lodge the yi and the patient goes into shock. In severe cases the shen also flees and they loose consciousness. The coma patient clearly is incapable of sensing, responding or information processing. (However, even in the vegetative state basic life functions are maintained thanks to the continuing presence of yuan shen.)
Kidney stores the zhi Kidney opens to the ear, and governs feng cang (seal store). The mental faculty associated with kidney-zhi therefore enables the perception of auditory information, and participates in and completes the storage of information. According to Lingshu Benshen, line 27, when spleen-yi processes are retained as part of the psyche’s stored experience, the kidney-zhi’s feng cang function performs this. Jing provides the material basis for all aspects of kidney physiology, so when jing is abundant the feng cang function is strong.
Where the heart-shen and kidney-zhi activities are not harmonised patients may experience auditory hallucinations. Kidney jing vacuity can disrupt this relationship and patients often encounter problems with memory or auditory function. Many elderly patients experience some degree of memory failure and/or auditory deficit corresponding to the decline of jing that normally occurs with age. Age-related Cognitive Decline is a recognised disorder where deterioration in mental function is related to the ageing process. Solving complex problems, or remembering names and appointments becomes more and more difficult with this condition. The impaired memory function and multiple cognitive deficits of Dementia patients also correspond to disordered kidney-zhi activity (see DSM-IV: 702 & 127).
To summarise the discussion so far, shen-zhi theory refers to wu shen activities and physiology. The theory is derived from the Lingshu Benshen, and describes how the five spirits participate in the experience and analysis of sensory perceptions and the cognitive processes of human consciousness.
The discussion of shen, hun, po, yi, and zhi above has largely relied on the separate and sequential presentation of each spirit. The reader will note that to some extent this is an artificial device, that wu shen activities are very closely integrated, and that the separation used here is for the purpose of clinical understanding and diagnostic identification. Although, it must be said that their individual characteristics and physiological relationships do contribute in particular ways to cognition and mentality.
During early life, post-heavenly wu xing differentiation proceeds in stages. Babies are known for sleeping rather than for thinking so at this early stage, differentiation emphasises the heart-shen, liver-hun and lung-po activities to ensure physical survival. The shen, hun and po also allow babies to receive sensory information from the external environment, and show how important this is for early development.
Immediately after birth, spleen-yi and kidney-zhi activities are minimal because at first, the infant’s middle qi and kidney qi are immature and unstable. Again, physiology and mentality are inseparable. Whilst sensory perceptions and responses arise relatively quickly, the cognitive processes involved in yi-zhi mentality, recollection, analysis, judgement and memory develop slowly over a number of years.
The Huangdi Neijing says the heart is the supreme commander and in the Lingshu Benshen its leading and co-ordinating role is presented in terms of the shen-hun-po-yi-zhi. Shen-zhi processes depend on close and harmonious relationships between the wu shen, and with their respective zang-viscera, ti-tissues, and guan-senses. Various aetiological and pathogenic factors can disrupt these relationships and their functions causing xing-shen (‘somatopsychic’ (Unschuld, 2003: 227)) disorder, or shen-zhi bing (mind disorder).
Section 4: Shen-zhi disharmony Healthy shen-zhi activity can be affected by factors from within or outside the body. In the Jingui Yaolue Clause 11-12 Zhang says that hun-po disorder (where ‘the patient cries out as if haunted…’) is due to depleted blood and qi. According to the Nanjing’s 20th Difficulty, a doubling of yang or yin will lead to insanity – mania in the case of excess yang or depression if the yin is excess. Qi or blood vacuity, yin-yang imbalance, or any other disturbance due to the usual pathogenic suspects (phlegm, blood stasis, heat, fire, toxins, and so on), can cause problems for shen-zhi activities.
When the wu shen are disordered the body-mind (xing-shen) relationships disintegrate and separate. This results in psychotic or neurotic signs and symptoms, such as visual hallucinations or hysterical paralysis. The following provide some clinical examples.
Shen-hun disharmony Shen-hun disharmony means that the shen and hun fail to follow each other. Sometimes this is called ‘shen is gone’ ( zou shen) or ‘hun is fallen’ ( diao hun). Typically, a person with either of these, watches but sees nothing. Such behaviour can indicate serious mental illness, but on the other hand is very common in mild forms of aphelxia such as daydreaming or absent-mindedness. Someone with shen-hun disharmony will to some extent be inattentive or indifferent to his or her external environment.
When the shen-hun relationship is disordered, the heart-shen cannot fulfil its function of receiving and co-ordinating information, and then, all the processes involved in perception, cognition, analysis, judgement and so on are interrupted and incomplete. Therefore, the shen-hun disharmony potentially encompasses many kinds of signs and symptoms but often, disturbance to normal sleep patterns is a key feature of the clinical presentation.
Insomnia and dream-disturbed sleep At night we are able to sleep peacefully when the shen and hun return to their lodgings in the heart and liver zang. Disturbed sleep and excessive dreaming occur if they fail to do this. In some cases the person can remember their dreams clearly when they wake. Because the shen’s governing role oversees the whole process of information perception and storage the patient with restless shen is able to remember their dreams.
When the patient cannot remember their dreams this is due to the hun failing to lodge/store: they cannot remember their dreams because the hun alone cannot process and remember. In many cases where there is sleep disturbance, both the shen and hun will require ‘settling’ treatment strategies. But when a patient cannot remember their dreams, more emphasis may be given to calming the hun.
Often an unsettled hun is associated with liver zang dysfunction and especially with patterns involving liver blood vacuity. Sleepwalking is another example of the hun failing to be stored.
Sleepwalking and shen wandering In the DSM-IV’s Sleepwalking Disorder there are ‘repeated episodes of complex motor behaviour initiated during sleep, … During [which], the individual has reduced alertness and responsiveness, [and] a blank stare…’ (p.604).
Here the hun and po take the body form for a walk. Together the hun and po can manage the functions of vision and movement to the extent that the sleepwalker can avoid obstacles and so on. But the hun-po cannot take the shen’s place in governing shen-zhi activity. Normal perception, processing and completion of cognitive information also require that heart-shen recalls (yi), and that yi is stored (zhi). Without the shen in charge, xing-shen are not unified, the person is unresponsive, their movements are abnormal, they cannot remember their sleepwalking and may not know where they are when they wake out of their bed.
Like sleepwalking, shen you ( shen wandering) is another example of shen and hun failing to follow each other. Shen you manifestations are similar to sleepwalking but the disturbance is more serious. Instead of occurring at night while asleep, shen wandering takes place during the day while awake. For example, in cases of Dissociative Fugue there is
…sudden, unexpected travel away from home or one’s customary place of daily activities, with inability to recall some or all of one’s past [and] accompanied by confusion about personal identity or even the assumption of a new identity… (DSM-IV: 493)
In shen and hun wandering cases the patient is extremely nervous and under immense pressure.
Shen-zhi bing In a general sense ‘shen-zhi bing’ ( spirit-mind disease) encompasses many kinds of mental disorder, both severe and less severe. An acute or long-term pattern where the shen and hun fail to follow can develop into a serious shen-zhi bing. This is a broad category similar to psychosis, in which the heart-shen cannot govern shen ming.
Suwen, Ling lan mi dian lun xin wei jun zhu zhi guan, shen ming chu yan. heart holds the office of supreme ruler, shen ming stems from it.
…Zhu ming ze xia an …if the ruler is bright there is peace below
…zhu bu ming ze shi er guan wei. …if the ruler is not bright the twelve officials are in grave danger.
Ming means bright, radiant, clear, so shen ming (spirit light) here signifies correct, healthy or spirited mentality and the power of human consciousness. Orderly heart-governing functions will have positive ramifications for all the body systems and especially the mind. But when the shen cannot process, co-ordinate or complete the information transmitted from the five sense organs, shen ming is disturbed, and this will result in mental illness.
Severe forms of shen-zhi bing correspond to schizophrenia and psychosis. Such cases present with grossly disorganised speech and behaviour, auditory, visual, olfactory, gustatory, and tactile hallucinations, catatonic stupor or excitement (DSM-IV: 281-2). From the TCM point of view the shen is severely disordered. Visual hallucinations, hysterical paralysis, trance, or catatonic stupor indicate that the hun and its functions are also disordered; and the patient’s feelings of physical discomfort are due to xing-shen disharmony.
As an aside we note that TCM’s dian ( withdrawal), kuang ( mania), and xian ( epilepsy) are severe forms of shen-hun failing to follow each other, and examples of severe shen-zhi bing. Whilst dian and kuang overlap with modern mental illness classifications, xian is a neurological disorder.
Less severe types of shen-zhi bing roughly correspond to modern psychiatry’s neurotic, depressive, or anxiety disorders. Two famous examples are given in Zhang Zhongjing’s Jingui Yaolue. Zang zao ( visceral agitation) in Clause 22-6 describes a woman who cries constantly as if haunted (see Garvey, 2001); and bai he bing ( lily disease) in Clause 3-1 provides an illustration for shen-po disharmony.
Shen po disharmony The lung-po participates in the physiological functioning of the skin, body hair and nose, and in the reception of tactile and olfactory information. A disordered shen-po relationship therefore can result in sensory and perceptive dysfunction. Olfactory information, or tactile and environmental sensations may become hypersensitive, distorted or disordered. According to Zhang Jiebing’s Leijing (Classified Canon), ‘The function of the corporeal soul is to enable the body to move and perform its function; pain and itching are felt by it.’ (Cited in Wiseman and Feng, 1998: 180)
This is why some patients with mental illness experience various kinds of paraesthesia, or present with abnormalities of psychomotor activity and mannerisms (pacing, rocking, grimacing, posturing). Stereotypic Movement Disorder includes more serious examples of repetitive, non-functional motor-behaviour including ‘head-banging, self-biting, picking at skin or bodily orifices, or hitting various parts of one’s own body.’ (DSM-IV: 123)
Some psychiatric patients cannot feel burning, seem insensitive to cold, or their clothes are inappropriate for the weather. Some do not realise they smell bad, are dirty, or are eating stool. Their skin and nasal tissues are physically normal, but the shen-po connection, the transmission and interpretation of sensory perceptions, is disordered.
Whilst modern TCM texts interpret Zhang’s bai he bing formulae for the treatment of lung and heart yin vacuity patterns, the features described in the Jingui Yaolue clearly emphasise the concomitant shen-po disharmony. The patient’s experience of hot and cold sensations are unrelated to fever, chills or environment; s/he may want to walk about, but soon becomes tired; although the food is delicious this person finds its smell repugnant. The desire to eat with dysphagia and the need for rest with restlessness is also typical of xing-shen disharmony: bodily responses are discordant with heart-shen inclinations.
Once again, we note that signs and symptoms corresponding to bai he bing can occur in mild cases or the early stages of degenerative neurological disorders such as Parkinsonism, Parkinson’s disease, or multiple sclerosis (Flaws & Lake, 2001). In modern practice and with appropriate clinical presentations, Zhang’s bai he bing can also apply to clinical depression or anxiety disorders, and to neuroses such as somatisation disorder or histrionic personality disorder. But importantly, although there may no organic explanation in the case of neurotic disorders, symptoms are not feigned and should be distinguished from factitious disorders and malingering (Garvey, 2001).
Conclusion It is almost a truism nowadays that the Chinese tradition does not radically distinguish between body and mind. Yet it would be a gross simplification to assume that body and mind are one and the same in the Chinese tradition. There is a distinction between the two in idea as well as language, but they are not understood as fundamentally different in nature. (Kohn, 1992: 169)
The notion of xing-shen in the Chinese medical tradition is patently dualistic, but there is little resemblance to the mind/body split of the European tradition. The xing and shen are more than intimately linked because, for the ancient Chinese and for modern students of Chinese medicine, the concept of ‘qi’ includes the convertibility of matter and energy. Consequently, ‘xing-shen’ presupposes a model of the human organism that is built on the functioning interrelatedness of material and energetic resources.
Shen-zhi theory elucidates important distinctions, interrelationships, and features of xing-shen physiology and disorder. The theory is derived from classical descriptions of the wu shen, and therefore draws upon wu xing systems of correspondence. To produce human consciousness the wu shen, their associated viscera, sense organs, tissues, and their harmonious interactions process a complex stream of visual, olfactory, taste, tactile, auditory and other perceived information. The smooth analysis and synthesis of information, the ability to respond, recall, and communicate, the accomplished elegance of human consciousness, are manifestations of orderly shen-zhi activity.
Here we have discussed the shen hun po yi zhi, and noted some of their functions and relationships. In order to do this we have followed the Lingshu Benshen’s use of the wu xing model in describing and distinguishing them. This not only provides a useful method to examine Chinese medicine’s ‘mind’ theory, but is helpful for the clinical analysis of ‘mind’ disease. Careful observation and correct understanding of signs and symptoms allow us to recognise pathogenic mechanisms, identify patterns, differentiate shen-zhi disorder, and thereby select appropriate treatment strategies and formulae.
The clinical models presented in modern TCM texts are drawn from its classical literature. And, while western psychiatry has investigated and categorised mental illness in great detail, TCM pattern and disease identification tend to favour broader categories. Therefore, TCM categories may overlap but do not always find direct correlations with modern psychiatric classifications. Thus, in its narrow sense shen-zhi bing refers to serious mental and neurological disorders such as schizophrenia and epilepsy. More broadly it refers to the theory of shen-zhi and to any functional disturbance causing spirit-consciousness, body-mind, and cognitive-sensory disorders.
bai he bing
Bai he bing, or ‘Lily Disease’ – is named after the entry in the Jingui Yaolue describing a state of mental and physical restlessness due to vacuity heat. Bai he (lily bulb) nourishes the heart and moistens the lung to calm the mind.
(kidney) seal and store
221 BCE to 207 BCE
mind, or spirit-mind
Warring States Period
475 – 221 BCE
five offices or sense organs
five body tissues
vacuity (weakness, depletion, emptiness)
Ideation (our ability to reflect, imagine, and form ideas)
(spleen) movement and transformation
(Full references for this article are printed in the hard copy of The European Journal of Oriental Medicine Vol. 5 No. 2; 2006.)
Qu Lifang Qu Lifang, Associate Professor, is a lecturer, clinician, and researcher in the Golden Cabinet Section of the Shanghai University of Chinese Medicine.
Mary Garvey Mary Garvey is a lecturer, clinician and PhD candidate at the College of TCM and Institute of International Studies at the University of Technology, Sydney.