Visceral Agitation (Zang Zao)

Visceral agitation is a paroxysmal mental disease most prevalent in women.

The viscus implied by the name is the heart, and the agitation refers to
agitation of the blood due to damaged Yin and to the rashness, impetuousity,
and impatience that characterize this condition. The Chinese literature
usually further says this condition is most common in adolescent females.
However, it may also be used to describe severe premenstrual tension, and it
is often seen in perimenopausal women. Visceral agitation often begins as
melancholy, depression and emotional lability but then progresses to
alternating laughing and crying for no reason, sighing for no apparent
reason, and vexation and agitation. In severe cases such as postpartum
when there has been a great loss of blood and body fluids, there may be
convulsions with a white facial complexion and possible complete loss of
consciousness.

Relevant Western Diseases: 

Psychoneurosis, depression, stress reactive types and hormonal psychosis

Differential Diagnosis: 
Medical Disorders:
1. CNS disorders, including mass lesions, seizure disorders, etc.
2. History of head trauma

Effects of Substances:
1. Alcohol or illicit substance intoxication or withdrawal
2. Side effects f medications

Psychiatric Disorders:
1. Histrionic Personality Disorder
2. Other Personality Disorders
3. Major Depressive Disorder
4. Bipolar Affective Disorder (BAD)
5. Premenstrual Dysphoric Disorder (PMDD)

TCM Etiology & Pathogenesis: 

“Visceral agitation is primarily due to lack of construction and nourishment of
the heart spirit and harassment of the spirit y some sort of evil heat. Lack of
construction and nourishment of the heart is, in turn, mainly due to heart-
spleen dual vacuity. Evil heat may be depressive heat, phlegm heat, or
vacuity heat. In real-life clinical practice, liver depression is always operative
in cases of visceral agitation. It is typically liver depression and spleen
vacuity which are the root mechanisms for heart-spleen dual vacuity and for
the engenderment of both depressive and phlegm heat.
Likewise, it is typically enduring or severe depressive heat which damages
and consumes Yin blood which then gives rise to Yin vacuity effulgent fire or
Yin vacuity Yang hyperactivity. Because most cases of visceral agitation
 present with at least four simultaneous disease mechanisms (liver
depression, depressive heat, spleen vacuity, and heart blood vacuity), the
heat involved in visceral agitation is perhaps best described as a species of
Yin fire”1 

“In general this disease is caused by stress, overexertion, poor diet,

pregnancy and postpartum difficulty, the pre heaven situation is also
considered a fundamental factor in this disease. Most commonly Zang Zao is
found in females, especially young middle and aged women with emotional
disharmony”2 

Prognosis: 
In general the symptoms will be relieved after treatment and almost all
patients can recover quickly. However, some patients have relevant pre
heaven situations which need Shen treatment; this psychological therapy
requires longer2

Diagnosis: 
1. Cry easily, depressed and moody
2. Irritable, sensitive and Shen weakness
3. Low energy and tiredness

Should have A, then refer others

TCM Pattern Differentiation: 

Qi and Blood Deficiency Failing to Nourish the Shen2 
Cries frequently and does not talk, or not clear why they feel such sadness,
may be crying and laughing improperly, also sensitive and Shen is very
weak, moody, upset, depressed, easily angered, low appetite an energy,
insomnia
Tongue: pale tongue, thin white coat
Pulse: weak, thready
Acupuncture Treatment: PC-6, HT-3, HT-7, GV-20, SP-6, KI-9, Yintang
Herbal Treatment: Gan Mai Da Zao Tang Modification2
[Gan Cao, Fu Xiao Mai, Da Zao]
Modifications: 
Heart Blood deficiency: + Shu Di Huang, Long Yan Rou
Heart Yin deficiency: + Bai Zi Ren, Bai He
Heart Qi deficiency: + Ren Shen, Dang Shen
Heart Fire: + Sheng Di Huang, Gan Cao Shao
Heart Shen sedating: + Zhen Zhu Mu, Ci Shi

Heart Spirit Lack of Nourishment1 

Devitalized essence spirit, abstraction, sorrowfulness without apparent cause
and abnormal laughing and crying, heart vexation, insomnia, profuse
dreams, susceptibility to fright, heart palpitations, lassitude of the spirit
Tongue: tender and red
Pulse: fine, bowstring
Treatment Principles: Enrich the heart and supplement the spleen, nourish
the blood and quiet the spirit
Acupuncture Treatment: GV-26, GV-20, PC-6, HT-7. Even technique
Acupuncture Modifications: 
During hysterical crisis: Use GV-26, PC-8, KI-1
Pronounced chest oppression: + CV-17
Plum pit Qi: + ST-40, CV-23, HT-5
Heart spirit lack of nourishment: + BL-15, BL-17, SP-6
Abnormal Laughing and weeping: + SI-3
Essence spirit abstraction: +BL-15, BL-47 
Herbal Treatment: 
Symptoms of Yin & Blood vacuity more pronounced: Gan Mai Da Zao Tang
Jia Wei1
[Suan Zao Ren (12g.), Sheng Di (12g.), Bai He (12g.), Gan Cao (10-15g.),
Huai Xiao Mai (15-30g.), Da Zao (5-15 pieces)]
Symptoms of liver depression more pronounced: Xiao Yao San He Gan Mai
Da Zao Tang Jia Wei1
[Chai Hu (6g.), Bo He (3-6g.), Bai Shao (10g.), Dang Gui (10g.), Bai Zhu
(10g.), Fu Shen (12g.), Gan Cao (10g.), Huai Xiao Mai (15-30g.), Suan Zao
Ren (12-15g.), Ye Jiao Teng (10-15g.), Da Zao (5 piece)]
If complicated by phlegm heat: Wen Dan Tang He Gan Mai Da Zao Tang Jia
Jian1
[Ban Xia (10g.), Fu Ling (10g.), Chen Pi (6g.), Zhi Ke (6g.), Zhu Ru (6-10g.),
Gan Cao (6g.), Chai Hu (6-10g.), Bai Shao (10g.), Xiang Fu (10g.), Dan Pi
(10g.), Zhi Zi (6g.), Huai Xiao Mai (15-30g.), Da Zao (5 pieces)]
Symptoms of Heart-Spleen dual vacuity more pronounced: Gui Pi Tang He
Gan Mai Da Zao Tang Jia Wei1
[Huang Qi (10-15g.), Dang Shen (10g.), Bai Zhu (10g.), Fu Shen (12g.),
Dang Gui (6-10g.), Log Yan Rou (10g.), Mu Xiang (6g.), Yuan Zhi (6-10g.),
Suan Zao Ren (12g.), Huai Xiao Mai (15-30g.),Da Zao (5 pieces),Shi Chang
Pu (6g.),Gan Cao (10g.)]
Modifications: 
Plum pit Qi: + Ban Xia, Hou Po
Even more pronounced Qi stagnation: + Fo Shou, He Huan Pi
Liver depression transformed into heat: + Dan Pi, Zhi Zi, Huang Qin

Heart-Liver Fire Effulgence1 

Heart vexation, easy anger, lack of tranquility when sitting or lying down,
crying and laughing without constancy, profuse dreams, susceptibility to
fright 
Tongue: red tongue, thin yellow coat
Pulse: fine, bowstring, rapid
Treatment Principles: Clear the liver and resolve depression, tranquilize
the heart and quiet the spirit
Acupuncture Treatment: LR-3, SP-6, GV-16, HT-8. Draining technique
Herbal Treatment: Dan Zhi Xiao Yao San Jia Wei1
[Zhi Shi Ying (15g.), Long Gu (12g.), Mu Li (12g.), He Huan Pi (12g.), Chai
Hu (9g.), Bai Zhu (9g.), Fu Ling (12g.), Dang Gui (9g.), Bai Shao (9g.), Dan
Pi (9g.), Shan Zhi (9g.), Gan Cao (6g.)]
Modifications: 
Severe heart vexation and insomnia: + Ci Shi, Mia Dong, Wu Wei Zi
Chest and rib-side distention & oppression w/ dry mouth & bitter taste:
+Huang Qin, Sheng Di, Qing Pi
Headaches and dizziness: + Shi Hue Ming, Ju Hua, Sang Ye

Liver-Kidney Insufficiency1 
Heart vexation, irritability, insomnia, heart palpitations, susceptibility to
fright, dry mouth, dry stools, 5-palm heat, dizziness, tinnitus, low back and
knee soreness and limpness
Tongue: red tongue, scanty possibly dry, possibly yellow coat
Pulse: fine, bowstring, rapid or surging, rapid
Treatment Principles: Enrich the kidneys and clear the liver, nourish the
heart and quiet the spirit
Acupuncture Treatment: GV-26, GV-20, HT-7, PC-6, KI-3, SP-6, CV-4.
Even technique
Herbal Treatment: 
Yin Vacuity/Vacuity heat: Bai He Di Tang He Zi Shui Qing Gan Yin1
[Bai He (10g.), Sheng Di (12g.) Shu Di (12g.), Shan Yao (10g.), Shan Zhu
Yu (10g.), Dan Pi (6-10g.), Fu Ling (10g.), Zi Xie (6-10g.), Chai Hu (3-6g.),
Bai Shao (10g.), Zhi Zi (6-10g.), Suan Zao Ren (12-15g.), Dang Gui (10g.)]
Yin Vacuity and Yang hyperactivity: Tian Ma Gou Teng Yin He Gan Mai Da
Zao Tang Jia Wei1
[Tian Ma (10g.), Gou Teng (10g.), Du Zhong (10g.), Niu Xi (10g.), Shi Jue
Ming (12g.), Sheng Di (12g.), Zhi Zi (6-10g.), Huang Qin (10g.), Chai Hu (6-
9g.), Fu Shen (12g.), Ye Jiao Teng (10-15g.), Huai Xiao Mai (10-15g.), Gan
Cao (6-10g.), Da Za (5 pieces)]
Yin vacuity with phlegm fire: Wen Dan Tang Jia Wei
[Ban Xia (12g.), Fu Ling (9g.), Chen Pi (9g.), Zhi Shi (6g.), Zhu Ru (9g.),
Dan Nan Xing (9g.), Ting Ling Zi (9g.), Zhi Mu (9g.), Mai Dong (12g.), Ye
Jiao Teng (12g.), Gan Cao (6g.), Da Zao (5 pieces)]
Modifications: 
Severe agitation: + KI-1
Pronounced liver depression: + LR-3, TW-6
Liver depression transforming into fire: + LR-2, GB-43
Chest oppression: + CV-17
Accompanying phlegm or Plum pit Qi: +ST-40
Accompanying Blood stasis: + SP-10