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Bipolar + Herbal Pattern Differentiation


Hello - this is my first post to yinyanghouse. I was wondering if someone could help distinguish between these two patterns for a patient of mine. She is already on prescription medication for bipolar disorder. She is interested in a herbal formula to possibly help minimize the amount of prescription drugs she is on. I have narrowed her down to two patterns. Either Phlegm Fire Harrassing the Heart or Blood Amasssment (Stasis). R

Patient is 30 year old female

I can not rely on her periods diagnostically since she is on the pill.

The signs she presents for Phlegm Fire Harrassing the Heart >

Mania / Depression symptoms ( although she is basically under control for any manic or depressive symptoms since she is regulated by her prescriptions.), Insomnia, Restlessness, Obsessive thoughts, Talks fast, Pulse - rapid strong, might be slippery?, Tongue - no thick yellow coat and only slightly red

The signs for Blood Amassment >

Mania / Depression symptoms ( although she is basically under control for any manic or depressive symptoms since she is regulated by her prescriptions.), Cramping lower abdominal pain, Restless, Always thirsty - drinks tremendous amount of water, Easily Bruises, Pulse - strong rapid, Tongue - slightly red, no coat

I was thinking of starting in conjunction with acupuncture one of the two formulas -

Phlegm Fire Harrassing the Heart > Formula - sheng tie luo yin

Although Sheng tie luo (Copper filings) have been removed from formula and shall remove - zhu sha, and add - da huang. Also thought I would add Shi Gao (Gypsum) or Zhi Mu (Anemarrhena) for her thirst if went with this formula


Blood Amassment > Tao he cheng qi tang

Does anyone have any insight for this case?

Thanks - Jacob


"Sheng tie luo yin" may right. "tao he cheng qi" is better change to "Chai Hu Shu Gan San", because female depression usually is Liver Qi stagnation, then become blood stagnation and body heat, the "Chai Hu, Zhi Qiao, Xiang Fu" can sooth liver Qi and expel depression, Chen Pi regular stomach Qi, and there are "Chuan Xiong, Bai shao, Gan cao" can promote blood movement and stop pain, those medicines inside the formula will much better control the second pattern, if not enough, you can add "Tao ren, Hong hua, Dan Shen" inside the Chai Hu Shu Gan San to promote body blood circulation.


Thanks for your reply - I appreciate it.

I had thought about treating Liver Stagnation - but the signs seemed too strong between these other two patterns. Although - I now do think it could be a good first formula and see how she respondsd and then maybe move on to Sheng tie luo yin + da huang.

Within the formula Chai Hu Shu Gan San, some of the ingredients can overlap and help her other signs and symptoms - such as -

Chai Hu

obviously for her stress, irritability, depression

Bai Shao

for her cramping and spasms of abdomen

supplement and nourish blood - harmonizing the liver

Chuan Xiong

help with her bruising – increase microcirculation

help with her abdominal pain caused by Qi and blood stasis

Supplement and nourish blood - harmonizing the liver

Moves qi within blood - effective for stopping pain.

Xiang Fu

Course the liver, rectify the qi

Zhi Ke

Course the liver, rectify the qi

Gan Cao

Abdominal pain

Harmonizes the other medicinals in the formula - With Bai Shao, it relaxes cramping and tension.

Thanks again for your input

- Jacob


I wonder if you might add some more weight to the tongue and pulse - strong psychological conditions often come from yin deficiency. Certainly the tongue with no coat can indicate yin deficiency. The rapidness in the pulse can be from yin deficiency. You would know better than I actually having seen the patient - it just stood out to me. I don&#39t see huge signs of blood stagnation or phlegm on the tongue or pulse except possibly the rapidness and symptoms wise these can all arise from yin deficiency and/or side effects from the meds which cannot be discounted either. Generally blood stagnation would lead to some purple on the tongue perhaps and perhaps some choppyness in the pulse and phlegm would, of course, often have a thicker tongue coating - although with heat that can get complicated.... And I&#39m sure you did this, but I often ask about their cycles before starting on birth control to get a better idea of the root - even if they have been on birth control for long periods of time.

Just an idea. If you feel there might be more to the yin and as Feng points out liver stagnation is often in there for women you could try Jia Wei Xiao Yao Wan during the day with Zhi Bai Di Huang Wan at night - both of which will help clear heat, move the liver, and build the yin to help cool the body and mind....


I agree with Chad. It more like yin deficiency plus yang excess. Other than Chad suggested, I would add more tonifying yin herbs, like "Tian Hua Fen", "Shen Di", "Xuan Shen", "Mai Dong", ect.


Thanks Chad for the great input. I now see exactly what you are saying. I shall look at her tongue again with her pulse. It might just be Heart Yin Deficiency?

The Phlegm Fire Harassing the Heart signs seemed so predominant - mania symptoms, insomnia, restlessness, Obsessive thoughts, Talks fast, Depression, Phlegm signs w/o heat being the mental confusion not so much phlegm - and the Blood Amassment as well seemed kind of predominant as well - cramping lower abdominal pain, restless, thirsty, and easy bruising.

I guess the bruising could be from yin deficiency? Being that the Shen is housed in the Heart and anchored by the Blood. Anxiety will result without the Blood to hold and calm the Shen. If blood is not stable - I assume that is where the bruising occurs through the yin deficiency.

Thanks again - I will check the tongue and pulse again.

All the best - Jacob


Thanks also for the input. I will look into the herbal options you recommended. Thanks for your time.


Yin deficiency is red tongue, little coating, pulse is thread weak, I don&#39t think she is yin deficiency, she just is Yang high pattern, add some cold medicine is right, but there is no reason for " Zhi Bai Di Huang Wan".


If you haven&#39t read it, I would recommend reading Giovanni Maciocia&#39s "the Psyche in Chinese Medicine." It&#39s a very impressive work and has a great section on "Dian Kuang" disorders - the closest thing we have in Chinese Medicine to what is called bipolar in the west. I was trying to find the actual page but somewhere in there he says that the most important indicator of yin deficiency is lack of tongue coating (over many other signs). So according to him - tongue in full heat (red/dark-red with a thick, dry, yellow or brown coat) and tongue in empty heat (red/dark-red without coating) and yin fire (pale with possibly a red tip). The pulse in yin defciency would be floating/empty and rapid and distringuishing between rapid and strong can be misleading. This is a vast generalization but if you are mixed between the two it is worth noting that women tend greatly towards blood/yin deficiency and men tend more towards yang excess - both because of personality styles, culture, diet, and menstruation (or lack thereof)....

He has a pattern in there (p.527) within the bipolar section: Yin Deficiency with Empty Heat - signs manic behavior, incessant talking, easily startled, insomnia - tongue red w/o coat, pulse fine-rapid and he recommends er yin jian (just as an example). I offer this to illustrate that the excessive talking and jubilant behavior can be either empty heat or fire....

Another way to help is to see if the tongue is swollen (indicate damp/phlegm) or thinner/normal... Certainly most of the phlegm/fire manifestations have indicative tongue coats (black, dry, yellow, thick, etc.)


Her mania and depression symptom already control by her own prescription, and she only has menstruate pain, and her pulse is strong, there is not any deficiency sympton, only body heat and thirsty, that mean she is Yang high without yin deficiency, if she has yin deficiency, she must has night sweating, and anxious heat at feet and hands and heart, there are no mention about these sympton.


That book is exactly what I need - thanks.


I am adding some info that I was reviewing about my patient that hopefully will shed some more light on this. I shall be seeing her in two days again and can add more diagnostics.


I need to re-look at pulse/tongue – but so far this is what I still think >

Pulse > Rapid, Strong

Tongue > Red Body, No Coat

I did notice her face when she came in and did not mention it since I thought it to be makeup/blush? I will need to ask her when I see her in two days. But her entire face was quite red? But I still think it could be makeup? Will look closer next time. Entire face would be Yang Excess and just the cheeks would be Yin Xu - correct?

Appetite > I also did not mention her appetite > she said she has lost 5 pounds and feels too skinny. She eats a lot but does not put any weight on. She is in good physical shape and does work out and do yoga. I would describe her as thin but not emaciated. She looks fit. So it would be a Yang Excess since she eats a lot - but does not gain weight?

Thirst > again is that she says she drinks a lot

Reproduction > Also neglected to mention that she said she has a strong sex drive and is a very sexual person. That could be both Yin Xu or Yang Excess? Not sure if she fatigues easily? - that might be more of a male issue anyhow?

Thanks again for putting so much devoted time into helping my patient. I really appreciate it


Yes, please send some more information when you see her again - particularly of the tongue and pulse and perhaps some probing to parcel out yin vs. yang symptoms - any night time heat, etc. It&#39s also good to ask her about her psychological issues before medications to see how she was really feeling. It is a common misconception that when people have conditions controlled on medicine that they "don&#39t have" this condition. What we do know is that if you remove the medicine in many conditions within days or weeks everything will come back as it was in many cases (hypertension, diabetes, psychological conditions, etc.). So probing about how things were before they were under control gives you an idea of some of the masking that may (or may not) be happening.

And don&#39t get me wrong, I&#39m not necessarily saying your diagnosis is incorrect - just that I didn&#39t see the phlegm signs or even strong blood stagnation signs - qi stagnation maybe with some kind of heat (yin or yang is not entirely clear with the information we have now). And simply to not assume empty heat cannot create the bipolar symptoms.

As an aside you might be interested to note that there was a clinical trial for the treatment of bipolar disorder with acupuncture - the final study abstract is here. It is a treatable condition in many cases and with Chinese Medicine it can lead to a resolution requiring no further treatment compared to being on medicine for life - or at least a combination will lead to less medication and better quality of life in most cases. So it is good she is coming to see you.

With regards to yin deficiency as Feng points outs you would ask questions about whether she has hot hands and/or feet particularly in the afternoon/evening - if there is an aggravation of symptoms in the evening, hot at night (does she sleep with little covers, with the air on low, with a fan, etc.) - she does not, however, have to have nightsweats to be yin deficient.

And, again, according to giovanni the lack of tongue coating on p192 "The tongue provides a crucial indication of Full Heat; in this condition, it is red with a yellow coating. If the tongue body is Red and there is a coating with root there is Full Heat (even if the coating is not yellow). If the tongue is Red but without coating (totally or partially), it is Empty Heat. The other important manifestation is the pulse; in Full Heat, this is Full in general (which may include Wiry, Overflowing, Big or Firm), it should also be rapid but frequently it is not ... In empty heat the pulse is floating-empty and rapid --- Yin Fire accounts for symptoms of Heat in mental emotional problems that may defy a classification into Full or Empty Heat - this is illustrated by symptoms of heat above (red face, thirst, hot face) with Cold below (cold feet, general cold feeling) (Yin Fire is treated by building original qi and not clearing heat/fire)....


Now it is more clear, if she is just Yang excess, the king medicine should be Shi Gao, add Da Huang for stomach heat will be ok, if she also yin deficiency, you can add Huang Bai, Zhi Mu. By the way, if she is realy blood stagnation, the tongue should has red dots, and pulse will also astringent feeling. Her sick location should be Liver and Stomach, maybe spleen also. right now no kidney yin deficiency sympton yet, because of her sexal power.


Hello Chad,

Thank you again for your great contributions for developing our knowledge :).

Few years ago I saw this great article, which helped me with treatment of one very dificult case of mine, who had bipolar disorder.



30 year old female - Bipolar

Mania / Depression

She is basically under control for any manic or depressive

symptoms since she is regulated by her prescriptions. Although she does

mention that the prescriptions are not completely helping her and she still

has some irregularities in her mood swings.



Obsessive thoughts

Speech > Rapid, Talks fast

Cramping lower abdominal pain + sometimes entire abdomen + Gas


Always thirsty - drinks tremendous amount of water

Complains of dry mouth no matter how much she drinks

Easily Bruises

Reproduction - Strong/Excess Sex Drive, Very Sexual person

Bowels – well formed – no constipation or diarrhea

Urine – takes vitamins – bright yellow

Appetite High > Eat a lot - does not gain weight

Menstruation > on the pill


Prior to Pill >

Menstruation : Started around 15yrs old

Heavy / Bad Cramps > Although lessened in severity with age

Mouth Sores – occassionally

Night Sweats – Sometimes/Not Regularly though, but when she does the sheets have been drenched

Tongue – Thick Coat : Yellow > middle + back of tongue, White Coat > sides

Pulse – Rapid and Wiry


Drink a lot of water is stomach strong heat, and hurt body yin energy, cause yin deficiency( night time sweat), for stomach heat use Shi Gao & Zhi Mu, for yin deficiency use Er Yin Jian, so this formula should combine with Shu Gao, Zhi Mu & Er Yin Jian+-.


I will look into different formulas that include Shi Gao, Zhi Mu & Er Yin Jian.

Thanks for all your help.


Have you had a chance to review the extra info? Thanks.

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