中医心身医学心身疾病的刚柔辩证

中医心身医学 心身疾病的刚柔辩证 中国中医科学院 赵 志 付 Psychosomatic Medicine of Traditional Chinese Medicine(TCM) Rigid- Gental Differentiation zhao zhi fu 1 一、应对心身疾病的挑战 1、 Coping with psychosomatic diseases 二、中医心身医学理论与临床 2、 The theory and clinical research of TCM Psychosomatic Medicine 2 一、应对心身疾病的挑战 1.Coping with psychosomatic diseases 3 随着世界经济的发展、社会 的进步和科学的日新月异，人类 的疾病谱和死亡谱发生了根本的 转变。 Disease spectrum and the cause of death have changed dramatically over the years, which have changed from mal nutrition and infection mainly to physical disorder resulting from mental or emotional and social causes, which are psychosomatic diseases. 4 由过去的传染病和营养不良 为主，转化为由心理社会因素生 活行为等因素引起的心身疾病为 主 .医学模式已由生物医学模式向 生物 心理 社会医学模式转化 。 5 中国也进入快速发展时期，社 会转型，市场经济，竞争加剧，人 际关系复杂，情绪压力增大。 21世纪是一个快速多变的，充 满了压力与挑战的时代 21st century is a time full of rapid changes, pressure and challenges. 6 亚 健 康 健 康 疾 病 心身疾病 其 他 7 1、消化系统心身疾病： 胃和十二指肠溃疡 (胃痛 )、慢性胃炎 (胃 痞 )、胃神经症 (胃胀 )、溃疡性结肠炎 (泄 泻、痢疾 )、 肠神经症 (泄泻 )、习惯性便秘 (便秘 )、慢 性肝炎 (胁痛 )、慢性胆囊炎 (胆胀 )、等。 Psychosomatic diseases in the digestive system include gastric and duodenal ulcer (stomachache), chronic gastritis (mass in the stomach), gastric neurosis (distension of the stomach), ulcerative colon (diarrhea and dysentery) 8 2、心血管系统心身疾病： 原发性高血压病 (眩晕 )、原发性低血压病 (眩 晕 )、冠心病 (胸痹 )、心律失常 (心悸 )、心脏 神经症 (胸痹 )、雷诺氏症 (厥证 )、 受体高 敏症 (心悸 )、 心因性晕厥 (厥症 )等。 Psychosomatic diseases in the cardiovascular system include primary hypertension (dizziness), essential hypotension (dizziness), coronary heart disease (obstruction of qi in the chest) 9 3、呼吸系统心身疾病： 支气管哮喘 (哮喘 )、过度换气综合症 ( 喘证 )、 神经性咳嗽 (肝咳 )等。 Psychosomatic diseases in the respiratory system include bronchial asthma (asthma), hyperventilation syndrome (dyspnea). syndrome) and nervous cough (dry cough 10 4、神经系统心身疾病： 脑卒中 (中风 )、癫痫 (痫证 )、血管神经 性头痛 (头痛 )、紧张性头痛 (头痛 )等。 Psychosomatic diseases in the nervous system include cerebral apoplexy (stroke), epilepsy (epilepsy), angioneurotic headache (headache) and tonic headache (headache). 11 5、内分泌系统心身疾病： 糖尿病 (消渴 )、甲亢 (瘿病 )、 肥胖病 (痰病 )、尿崩症 (消渴 )、 心因性多饮 (消渴 )等。 Psychosomatic diseases in the endocrine system include diabetes (diabetes), hyperthyroidism (goiter), obesity (phlegm syndrome), diabetes insipidus (diabetes), and psychogenic excessive drink of water (diabetes). 12 6、泌尿生殖系统心身疾病 ： 前列腺炎 (白浊 )，过敏性膀胱炎 (淋症 ) 、 尿道综合症 (淋症 )、原发性性功能障碍 (阳痿、早泄 )等 Psychosomatic diseases in the urogenital system include prostatitis (gonorrhea), allergic cystitis (stranguria), urethral syndrome (stranguria) and primary sexual disorder (impotence and premature ejaculation). 13 7、骨骼肌肉系统心身疾病 ： 类风湿 (痹证 )、全身肌肉痛 (痹证 )、 书写痉挛 (振颤 )、局部性肌痉挛 (振颤 ) 等。 Psychosomatic diseases in the skeletal and muscular systems include rheumatoid disease (arthralgia syndrome), pain in muscles throughout the body (arthralgia syndrome), writing spasm (tremor) and local muscular spasm (tremor). 14 8、外科系统心身疾病： 包括腹部手术不适综合证 (腹痛 )、 肠粘连症 (便秘 )，等。 Psychosomatic diseases in the surgical department include uncomfortable syndrome of abdominal operation (abdominal pain) and intestinal adhesion (constipation). 15 9、妇产科心身疾病： 包括痛经 (痛经 )、闭经 (经闭 )、月经不调 ( 月经先期、后期、先后不定 )、功能性子 宫出血 (崩漏 )、更年期经前后诸症 )、不孕 症 (不孕 ) Psychosomatic in the department ofgynecology andobstetricsincludedysmenorrhea(dysme norrhea), amenia(amenia), irregular menstruation (advanced ordelayedenstruation),dysfunctional uterine bleeding (metrorrhagiaandmetrostaxis), menopausalsyndrome(diseasesaroundmen opause) and infertility (infertility). 16 10、儿科心身疾病： 神经性厌食症 (厌食 )、遗尿症 (遗尿 )、 腹痛 (腹痛 )、头痛 (头痛 )等。 Psychosomatic diseases in the department of pediatrics include nervous anorexia (anorexia), enuresis (enuresis), abdominal pain (abdominal pain) and headache (headache). 17 11、皮肤科心身疾病： 湿疹 (湿毒疮 )、牛皮癣 (白疮 )、痤疮 ( 粉刺 )、斑秃 (油风 )、慢性麻疹 (风疹块 )、多汗症 (汗证 )、皮肤瘙痒症 (风搔痒 )等。 Psychosomatic diseases in the department of dermatology include eczema (noxious dampness), psoriasis, acne (acne), alopecia areata (alopecia areata), chronic urticaria (rubella), hyperhidrosis (sweating syndrome) and cutaneous pruritus (pruritus cutis). 18 12、眼科心身疾病： 原发性青光眼 (五风内障 )、中心性视网 膜炎 (视惑 )、飞蚊症 (云雾移晴 )、白内障 (园翳内障 )、眼睛癔症 (暴盲 )等 Psychosomatic diseases in the department of ophthalmology include primary glaucoma (glaucoma), central choroido-retiritis (blurring vision), flying mosquito disease (vitreous opacity), cataract (cataract) and ocular hysteria (sudden loss of vision). 19 13、耳鼻喉科心身疾病： 心因性耳聋 (耳聋 )、美尼尔氏征 (眩晕 ) 、 失音 (喉喑 )、过敏性鼻炎 (鼻鼽 )等。 Psychosomatic diseases in the department of otolaryngology include psychogenic deafness (deafness), Menieres disease (dizziness), aphonia (aphonia due to throat disease) and allergic rhinitis (allergic rhinitis). 20 14、口腔科心身疾病： 口臭 (口臭 )、口腔溃疡 (口疮 )、 特发 性舌痛 (舌痛 )、心因性牙痛 (牙痛 )等。 Psychosomatic diseases in the department of stomatology include ozostomia (ozostomia), stomatocace (aphthae), idiopathic glossalgia (glossalgia), psychogenic toothache (toothache). 21 15、肿瘤科心身疾病： 胃癌 (积聚 )、肝癌 (胁痛 ) 肠癌 (便血 ) 、 食道癌 (噎嗝 )等。 Psychosomatic diseases in the department of tumor include carcinoma of stomach (abdominal mass), liver cancer (hypochondriac pain), intestinal cancer (hemafecia) and carcinoma of esophagus (dysphagia). 22 16.心身性亚健康 Sub-Health 23 应对心身疾病的挑战是世界医学的 共同责任， 1977年美国提出医学模式转 变，但至今没有形成完整的理论和方法 ，没有实现心身整合的目标。 It is our resposibility to cope with psychosomatic diseases. However since 1977 changing the medicine model was emeraged in the US, there is not a complete theory and clinical method yet. 24 1990年去日本九州大学医学部向国际心 身医学会理事长池见酉次郎教授学习 。 25 1996年去日本九州大学医学部心疗内 科，进修心身医学。现任亚洲心身医 学会会长久保千春教授 。 26 中医学治疗心身疾病有得天独中医学治疗心身疾病有得天独 厚的优势，受到国际心身医学界厚的优势，受到国际心身医学界 的重视。国际心身医学界权威人的重视。国际心身医学界权威人 士指出：士指出： “ 世界心身医学要向中世界心身医学要向中 医学寻找智慧。医学寻找智慧。 ” At an international conference on psychosomatic medicine in 1992, authoritative sources pointed out: “Psychosomatic medicine in the world should look for wisdom from TCM”. 27 存在决定意识，需求决定发展，防 治心身疾病成为医学发展的方向，压力 性疾病即心身疾病越来越多，超过以往 任何时期。 Demand determines development. The prevention and cure of psychosomatic diseases is the new direction of medicine. 中医学的创新与发展 28 二、中医心身医学理论与临床 2.The theory and clinical research of TCM Psychosomatic Medicine 29 1、中医学发展的新时代、中医学发展的新时代 (1)The new stage of TCM 30 第一个时代 春秋 战 国 时 期 The first stage-Spring and Autumn and Warring States periods of China (770 BC -221 BC) 精气学说、阴阳学说、五行学 说、脏象学说、以及病因病机 ，诊断治疗，预防养生等各个 方面。 黄帝内经 31 第二个时代 东汉时期 The second stage- Eastern Han Dynasty (25AD- 220AD) 三阴三阳的伤寒病六经辩证 经方派 伤寒论 32 第三个时代 金元时期 The third stage-Jin and Yuan Dynasty (1115AD-1368AD) 刘完素 张子和 李东垣 朱丹溪 寒凉 攻下 补土 滋阴 金元四大家 33 第四个时代 清代 The fourth stage-Qing Dynasty (1644-1911AD) 叶天士 吴鞠通 等 温病卫气营血辩证和三焦辩证 温热论 34 The fifth stage- Psychosomatic Medicine 心身医学的时代第五个时代 35 2、心身疾病的中医病因病机研究、心身疾病的中医病因病机研究 (2) Research on Etiology and Pathogenesis of TCM psychosomatic medicine 36 “ 形神合一论 ”“ 天人 合一论 ”“ 脏腑相关论 ”“ 阴阳五行学说 ” 。 “The theory on combination of physique and mentality into one”, “the theory on correspondence between man and universe”, “the theory on relations between zang and fu” and “the theory on yin- yang and five elements” Neijing (Internal Classic) 37 “ 主明则下安 ，主不明则十 二官危，使道闭塞不通，形乃大 伤 ”“ 悲哀愁忧则心动，心动则 五脏六腑皆摇 ”“ 精神内伤，身 必败亡 ” 精辟地阐述了心理对生 理的影响 “Mentality in order makes physique healthy Mentality in disorder makes twelve organs sick, tracts obstructed and physique seriously damaged.” “Sadness and depression make the heart disturbed, affecting all internal organs.” Neijing 38 “ 人之有生也，有阴有阳，有短有 长，有柔有刚 ” 。中医的心理生理 具有阴阳刚柔对立统一的特点 ,归 纳为 “ 中医刚柔心身论 ” (刚柔心 理生理学说 )。 “People by birth have yin and yang, short and long, flexibilityandrigidity.”Therefore,TCM psychophysiology is characterized by the unity of opposites between yin and yang and between flexibility and rigidity. The authors sum it up as “the flexible-rigid theory on TCM psychosomatic medicine” (the flexible- rigid doctrine on psychophysiology). 39 关于病因 内经 的正 (内因 )， 邪 (外因 )学说与现代心身医学认 识一致。内因有先天禀赋、气质 、体质。外因有七情、六淫和饮 食劳逸等。是心理、社会、生物 、生活方式、行为等各种应激因 素。 Neijing is identical to modern psychosomatic medicine in the theory on internalandexternalfactors.Internalfactors includecongenitalendowment,temperame nt and physique. External factors include seven emotions, six climatic conditions ,diet, labor and rest. 40 调查内因可以找出心理素质和 生理素质的虚弱所在，即正气虚的 表现。调查外因则可找出心理、社 会、生物、行为诸种致病因素，即 邪气实的表现。 Investigation into internal factors can find what are feeble in psychological and physiological quality, which is manifested in deficiency of vital qi.Investigation into external factors can find disease-causing factors of psychology, sociality, biology and behavior, which is manifested in excess of pathogen. 41 If the patient was noble in the past and is now humble, although he had not attacked by the evil, he has disease produced from the interior. If he was rich in the past and is now poor that causes the diseases. 凡诊病者，必问尝贵后贱，虽不 中邪，病从内生，名曰脱营 INTERNAL CLASSIC 42 Anger injuries liver, joy injuries heart, grief injuries lung, thinking injuries spleen and fear injuries kidney Internal classic 怒伤肝 、喜伤心、思伤脾、忧伤肺 、 恐伤肾 43 3、心身疾病的治疗、心身疾病的治疗 (3)The treatment to psychosomatic diseases 44 心身疾病的中医心身疾病的中医治疗，历来强调治疗，历来强调“ 先治其心，而先治其心，而 后医其身后医其身 ” 。笔。笔 者近者近 10 多年来，多年来， 把中医心身治疗把中医心身治疗方法归纳为方法归纳为 9种，种， 即中医心理治疗即中医心理治疗、中医行为矫正、中医行为矫正治疗，中医心理治疗，中医心理药物治疗，辩证药物治疗，辩证治疗，食物疗法治疗，食物疗法，针灸治疗，推，针灸治疗，推拿疗法，道家松拿疗法，道家松静疗法，药枕浴静疗法，药枕浴足疗法足疗法 。 45 In the treatment of psychosomatic diseases, TCM always stresses “psychological treatment before physiological treatment”. The authors have for more than a decade summarized TCM methods for the treatment of psychosomatic diseases as of 9 types.(九宝合璧 ) 46 4、心身疾病的刚柔辩证 （ 4） Rigid-Gental Differentiation of Psychosomatic diseases 根据国内外的资料和自己的临床实 践总结如下 ： 47 发病后首先伤肝，波及心、脾 、肺，日久及肾。初期多为肝脾同 病，肝心同病，肝肺同病，后期多 为肝肾阴虚或肝脾肾的阳虚。末期 阴竭、阳亡、阴阳离绝而终。 In early stage, the diseases are mainly at both liver and spleen, both liver and heart, or both liver and lung. In late stage, the diseases are mainly manifested in yin-deficiency of the liver and kidney or yang-deficiency of the liver, spleen and kidney. In the end, the patient dies of yin- failure, yang-vanish and complete separation of yin from yang. 48 病性为刚柔不能相济， 而致疏泄失职，气滞血瘀， 痰阻湿困或气逆化火，火热 伤阴，升降失司，日久由实 转虚，脾虚肝郁或肾虚肝旺 ，极少纯虚证。 （看下张英文） 49 The nature of illness belongs to flexibility and rigidity unable to supplement each other, causing abnormal flow of qi, qi stagnation, blood stasis, obstruction of phlegm, retention of dampness, fire due to adverse flow of qi, impairment of yin due to fire, and disorder in ascension and descension. Lingering illness will transform from excess to deficiency syndrome with deficiency of the spleen, stagnation of the liver-qi or deficiency of the kidney and excess of the liver-fire. Very few patients suffer from deficiency syndrome. 50 心身疾病经过及时合理的治疗，多有 较好的疗效，但容易因情志因素复发。 Fairly good curative effects can be achieved in most patients with psychosomatic diseases through reasonable and timely medical treatment. However, these diseases easily recur due to emotional factors. 51 少数患者因治疗不当，可由实转虚 ，最后阴亡或阳亡而终。另有少数 患者可因剧烈的情志刺激、气血暴 逆或气血暴脱，精去神亡。 Patients with improper treatment can transform from excess to deficiency and will finally die of yin-vanish or yang-vanish. Other patients could die of suddenly adverse flow of qi and blood or sudden collapse of qi and blood due to violent emotional stimulation. 52 心身疾病刚柔辨证论治 心理社会压力 情志过激 伤肝 刚 证 柔 证 病机 素体性急阳刚疏泄太过肝旺成刚证 实 证 肝气上逆 抑肝降逆 肝火上炎 泻肝降火 心肝火旺 泻肝清心 心肝火旺痰瘀互结 泻肝清心化痰活血 虚 证 心肝阴虚 柔肝养心 肝肾阴虚肝阳上亢 滋阴平肝潜阳 肝肾阴虚风动 滋补肝肾熄风 阴损及阳 滋阴助阳 结局 阴亡阳亡 素体性缓阴柔疏泄不及成柔证 肝郁气滞 疏肝理气 肝郁血瘀 疏肝活血 肝郁脾困 疏肝理脾 肝郁痰湿阻肺 疏肝化痰理肺 肝郁脾虚 疏肝健脾 心肝气虚 补肝养心 脾肾阳虚 温补脾肾 阳损及阴 补阳助阴 阳亡阴亡 53 心身疾病刚证柔证辩证论治 心理社会压力、情志刺激 首先伤肝首先伤肝 实证 素体性急阳刚疏泄太过 肝旺一 刚证 肝气上逆一抑肝降逆 肝火上炎一泻肝降火 心肝火旺一泻肝清心 心肝火旺痰瘀互结一泻肝清心化痰活血 素体性缓阴柔疏泄不及一肝郁一 柔证 肝郁气滞一疏肝理气 肝郁血瘀 疏肝活血 肝郁脾困一疏肝理脾 肝郁痰湿阻肺一疏肝理肺化痰虚证 心肝阴虚 柔肝养心 肝肾阴虚肝阳上亢 滋阴平肝潜阳 肝肾阴虚风动 滋补肝肾熄风 阴损及阳 滋阴助阳 肝郁脾虚一疏肝健脾 心肝气虚一补肝养心 脾肾阳虚 温补脾肾 阳损及阴一补阳助阴 结 局 阴亡阳亡 阳亡阴亡 54 There are 2 classes, 4 items, 16 families in differentiation of syndromes according to the Rigid-Gental theory. 55 2 classes are: Rigid Symptom, Gental symptom 4 items are: Rigid-excess Symptom Gental-excess symptom Rigid-deficiency Symptom Gental-deficiency symptom 56 Rigid-excess Symptom 刚实证刚实证 Up inverse of liver Qi 肝气上逆 Excessive fire of liver 肝火上炎 Excessive fire of liver and heart 心肝火旺 Excessive fire of liver and heart with phlegm and blood stasis 心肝火旺痰瘀互结 57 Gental-excess Symptom 柔实证柔实证 Stasis of liver Qi 肝 郁气滞 Stasis of liver blood 肝郁血瘀 Stasis of liver and spleen Qi 肝 郁脾困 Stasis of liver Qi and phlegm stagnate in lung 肝郁痰湿阻肺 58 Rigid-deficiency Symptom 刚虚症刚虚症 Insufficient yin of liver and heart 心肝阴虚 Insufficient yin of liver and kidney with inverse liver yang 肝肾阴虚肝阳上亢 Insufficient yin of liver and kidney with internal wind activity 肝肾阴虚风动 Insufficient yin result in insufficient yang 阴损及阳 59 Gental-deficiency Symptom 柔虚症柔虚症 Stasis of liver and insufficient of spleen 肝郁脾虚 Insufficient Qi of heart and liver 心肝气虚 Insufficient Yang of spleen and kidney 脾肾阳虚 Insufficient Yang result in insufficient Yin 阳损及阴 60 Rigid Symptom 症状症状 Gental symptom 症状症状 irritated spirit易怒 tired spirit易疲 red complexion 面 红 sallow complexion 面白 Obesity肥胖 Emaciation瘦弱 tongue coating is yellow苔黄 tongue coating is white苔白 Halitosis口臭 fishy smell口腥 61 Rigid Symptom 症状症状 Gental symptom症状症状 Edgy急躁 Gentle温和 Impatient无耐心 Patient耐心 speak loudly & quickly 声高 语 快 speak softly & slowly 声柔 语 慢 Active活 跃 Quiet安静 Easily express emotion 善于表达感情 Hardly express emotion不易表达感情 62 心身疾病的中医诊断，继承传统 的四诊，辨病和辨证，再吸收现代 心身医学的心理诊断和躯体诊断两 部分内容。躯体诊断与一般西医诊 断相同。为中医心身疾病的疗建立 客观依据。 On diagnosis of psychosomatic diseases in TCM, four traditional diagnoses, differentiation of diseases and syndromes should be inherited, and psychological and physiological diagnoses in modern psychosomatic medicine should be absorbed. TCM is identical to Western medicine in physiological diagnosis. 63 5、病 例 Case Report 64 Case Report Mr. Han, 49y 男， 49岁 Complaint: chest pain and tightness for 3 days 主诉：胸憋胸痛 3天 65 History: he complained chest pain and tightness for 3 days and felt gradually severe because of nervous. He went to a hospitals emergency department and was not excluded of cardiac infarct by ECG. But later coronary arteriography showed normal and no evidence of infarct. 工作紧张的人、症状不断加剧、急诊住院、冠状造影排 除心梗 病 例 66 Treatment to symptoms was not effective. The doctor there referred him to our traditional Chinese