中医心身医学——心身疾病的刚柔辩证.ppt

1,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PsychosomaticMedicineofTraditionalChineseMedicine(TCM)Rigid-GentalDifferentiationzhaozhifu,2,一、应对心身疾病的挑战1、Copingwithpsychosomaticdiseases二、中医心身医学理论与临床2、ThetheoryandclinicalresearchofTCMPsychosomaticMedicine,3,一、应对心身疾病的挑战1.Copingwithpsychosomaticdiseases,4,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。Diseasespectrumandthecauseofdeathhavechangeddramaticallyovertheyears,whichhavechangedfrommalnutritionandinfectionmainlytophysicaldisorderresultingfrommentaloremotionalandsocialcauses,whicharepsychosomaticdiseases.,5,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。,6,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21stcenturyisatimefullofrapidchanges,pressureandchallenges.,7,亚健康,健康,疾病,心身疾病,其他,8,1、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。Psychosomaticdiseasesinthedigestivesystemincludegastricandduodenalulcer(stomachache),chronicgastritis(massinthestomach),gastricneurosis(distensionofthestomach),ulcerativecolon(diarrheaanddysentery),9,2、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。Psychosomaticdiseasesinthecardiovascularsystemincludeprimaryhypertension(dizziness),essentialhypotension(dizziness),coronaryheartdisease(obstructionofqiinthechest),10,3、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。Psychosomaticdiseasesintherespiratorysystemincludebronchialasthma(asthma),hyperventilationsyndrome(dyspnea).syndrome)andnervouscough(drycough,11,4、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。Psychosomaticdiseasesinthenervoussystemincludecerebralapoplexy(stroke),epilepsy(epilepsy),angioneuroticheadache(headache)andtonicheadache(headache).,12,5、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。Psychosomaticdiseasesintheendocrinesystemincludediabetes(diabetes),hyperthyroidism(goiter),obesity(phlegmsyndrome),diabetesinsipidus(diabetes),andpsychogenicexcessivedrinkofwater(diabetes).,13,6、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Psychosomaticdiseasesintheurogenitalsystemincludeprostatitis(gonorrhea),allergiccystitis(stranguria),urethralsyndrome(stranguria)andprimarysexualdisorder(impotenceandprematureejaculation).,14,7、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。Psychosomaticdiseasesintheskeletalandmuscularsystemsincluderheumatoiddisease(arthralgiasyndrome),paininmusclesthroughoutthebody(arthralgiasyndrome),writingspasm(tremor)andlocalmuscularspasm(tremor).,15,8、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。Psychosomaticdiseasesinthesurgicaldepartmentincludeuncomfortablesyndromeofabdominaloperation(abdominalpain)andintestinaladhesion(constipation).,16,9、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)Psychosomaticinthedepartmentofgynecologyandobstetricsincludedysmenorrhea(dysmenorrhea),amenia(amenia),irregularmenstruation(advancedordelayedenstruation),dysfunctionaluterinebleeding(metrorrhagiaandmetrostaxis),menopausalsyndrome(diseasesaroundmenopause)andinfertility(infertility).,17,10、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。Psychosomaticdiseasesinthedepartmentofpediatricsincludenervousanorexia(anorexia),enuresis(enuresis),abdominalpain(abdominalpain)andheadache(headache).,18,11、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。Psychosomaticdiseasesinthedepartmentofdermatologyincludeeczema(noxiousdampness),psoriasis,acne(acne),alopeciaareata(alopeciaareata),chronicurticaria(rubella),hyperhidrosis(sweatingsyndrome)andcutaneouspruritus(prurituscutis).,19,12、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Psychosomaticdiseasesinthedepartmentofophthalmologyincludeprimaryglaucoma(glaucoma),centralchoroido-retiritis(blurringvision),flyingmosquitodisease(vitreousopacity),cataract(cataract)andocularhysteria(suddenlossofvision).,20,13、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。Psychosomaticdiseasesinthedepartmentofotolaryngologyincludepsychogenicdeafness(deafness),Menieresdisease(dizziness),aphonia(aphoniaduetothroatdisease)andallergicrhinitis(allergicrhinitis).,21,14、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。Psychosomaticdiseasesinthedepartmentofstomatologyincludeozostomia(ozostomia),stomatocace(aphthae),idiopathicglossalgia(glossalgia),psychogenictoothache(toothache).,22,15、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。Psychosomaticdiseasesinthedepartmentoftumorincludecarcinomaofstomach(abdominalmass),livercancer(hypochondriacpain),intestinalcancer(hemafecia)andcarcinomaofesophagus(dysphagia).,23,心身性亚健康Sub-Health,24,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。Itisourresposibilitytocopewithpsychosomaticdiseases.Howeversince1977changingthemedicinemodelwasemeragedintheUS,thereisnotacompletetheoryandclinicalmethodyet.,25,1990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。,26,2019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。,27,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的重视。国际心身医学界权威人士指出：“世界心身医学要向中医学寻找智慧。”Ataninternationalconferenceonpsychosomaticmedicinein1992,authoritativesourcespointedout:“PsychosomaticmedicineintheworldshouldlookforwisdomfromTCM”.,28,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。Demanddeterminesdevelopment.Thepreventionandcureofpsychosomaticdiseasesisthenewdirectionofmedicine.中医学的创新与发展,29,二、中医心身医学理论与临床2.ThetheoryandclinicalresearchofTCMPsychosomaticMedicine,30,1、中医学发展的新时代(1)ThenewstageofTCM,31,第一个时代春秋战国时期Thefirststage-SpringandAutumnandWarringStatesperiodsofChina(770BC-221BC),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,32,第二个时代东汉时期Thesecondstage-EasternHanDynasty(25AD-220AD),三阴三阳的伤寒病六经辩证经方派,伤寒论,33,第三个时代金元时期Thethirdstage-JinandYuanDynasty(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,34,第四个时代清代Thefourthstage-QingDynasty(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,35,Thefifthstage-PsychosomaticMedicine,心身医学的时代,第五个时代,36,2、心身疾病的中医病因病机研究(2)ResearchonEtiologyandPathogenesisofTCMpsychosomaticmedicine,37,“形神合一论”“天人合一论”“脏腑相关论”“阴阳五行学说”。“Thetheoryoncombinationofphysiqueandmentalityintoone”,“thetheoryoncorrespondencebetweenmananduniverse”,“thetheoryonrelationsbetweenzangandfu”and“thetheoryonyin-yangandfiveelements”,Neijing(InternalClassic),38,“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.“MentalityinordermakesphysiquehealthyMentalityindisordermakestwelveorganssick,tractsobstructedandphysiqueseriouslydamaged.”“Sadnessanddepressionmaketheheartdisturbed,affectingallinternalorgans.”,Neijing,39,“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)。“Peoplebybirthhaveyinandyang,shortandlong,flexibilityandrigidity.”Therefore,TCMpsychophysiologyischaracterizedbytheunityofoppositesbetweenyinandyangandbetweenflexibilityandrigidity.Theauthorssumitupas“theflexible-rigidtheoryonTCMpsychosomaticmedicine”(theflexible-rigiddoctrineonpsychophysiology).,40,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。Neijingisidenticaltomodernpsychosomaticmedicineinthetheoryoninternalandexternalfactors.Internalfactorsincludecongenitalendowment,temperamentandphysique.Externalfactorsincludesevenemotions,sixclimaticconditions,diet,laborandrest.,41,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。Investigationintointernalfactorscanfindwhatarefeebleinpsychologicalandphysiologicalquality,whichismanifestedindeficiencyofvitalqi.Investigationintoexternalfactorscanfinddisease-causingfactorsofpsychology,sociality,biologyandbehavior,whichismanifestedinexcessofpathogen.,42,Ifthepatientwasnobleinthepastandisnowhumble,althoughhehadnotattackedbytheevil,hehasdiseaseproducedfromtheinterior.Ifhewasrichinthepastandisnowpoorthatcausesthediseases.凡诊病者，必问尝贵后贱，虽不中邪，病从内生，名曰脱营,INTERNALCLASSIC,43,Angerinjuriesliver,joyinjuriesheart,griefinjurieslung,thinkinginjuriesspleenandfearinjurieskidneyInternalclassic怒伤肝、喜伤心、思伤脾、忧伤肺、恐伤肾,44,3、心身疾病的治疗(3)Thetreatmenttopsychosomaticdiseases,45,心身疾病的中医治疗，历来强调“先治其心，而后医其身”。笔者近10多年来，把中医心身治疗方法归纳为9种，即中医心理治疗、中医行为矫正治疗，中医心理药物治疗，辩证治疗，食物疗法，针灸治疗，推拿疗法，道家松静疗法，药枕浴足疗法。,46,Inthetreatmentofpsychosomaticdiseases,TCMalwaysstresses“psychologicaltreatmentbeforephysiologicaltreatment”.TheauthorshaveformorethanadecadesummarizedTCMmethodsforthetreatmentofpsychosomaticdiseasesasof9types.(九宝合璧),47,4、心身疾病的刚柔辩证（4）Rigid-GentalDifferentiationofPsychosomaticdiseases,根据国内外的资料和自己的临床实践总结如下：,48,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。Inearlystage,thediseasesaremainlyatbothliverandspleen,bothliverandheart,orbothliverandlung.Inlatestage,thediseasesaremainlymanifestedinyin-deficiencyoftheliverandkidneyoryang-deficiencyoftheliver,spleenandkidney.Intheend,thepatientdiesofyin-failure,yang-vanishandcompleteseparationofyinfromyang.,49,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）,50,Thenatureofillnessbelongstoflexibilityandrigidityunabletosupplementeachother,causingabnormalflowofqi,qistagnation,bloodstasis,obstructionofphlegm,retentionofdampness,fireduetoadverseflowofqi,impairmentofyinduetofire,anddisorderinascensionanddescension.Lingeringillnesswilltransformfromexcesstodeficiencysyndromewithdeficiencyofthespleen,stagnationoftheliver-qiordeficiencyofthekidneyandexcessoftheliver-fire.Veryfewpatientssufferfromdeficiencysyndrome.,51,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。Fairlygoodcurativeeffectscanbeachievedinmostpatientswithpsychosomaticdiseasesthroughreasonableandtimelymedicaltreatment.However,thesediseaseseasilyrecurduetoemotionalfactors.,52,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。Patientswithimpropertreatmentcantransformfromexcesstodeficiencyandwillfinallydieofyin-vanishoryang-vanish.Otherpatientscoulddieofsuddenlyadverseflowofqiandbloodorsuddencollapseofqiandbloodduetoviolentemotionalstimulation.,53,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,54,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,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,55,Thereare2classes,4items,16familiesindifferentiationofsyndromesaccordingtotheRigid-Gentaltheory.,56,2classesare:RigidSymptom,Gentalsymptom4itemsare:Rigid-excessSymptomGental-excesssymptomRigid-deficiencySymptomGental-deficiencysymptom,57,Rigid-excessSymptom刚实证,UpinverseofliverQi肝气上逆Excessivefireofliver肝火上炎Excessivefireofliverandheart心肝火旺Excessivefireofliverandheartwithphlegmandbloodstasis心肝火旺痰瘀互结,58,Gental-excessSymptom柔实证,StasisofliverQi肝郁气滞Stasisofliverblood肝郁血瘀StasisofliverandspleenQi肝郁脾困StasisofliverQiandphlegmstagnateinlung肝郁痰湿阻肺,59,Rigid-deficiencySymptom刚虚症,Insufficientyinofliverandheart心肝阴虚Insufficientyinofliverandkidneywithinverseliveryang肝肾阴虚肝阳上亢Insufficientyinofliverandkidneywithinternalwindactivity肝肾阴虚风动Insufficientyinresultininsufficientyang阴损及阳,60,Gental-deficiencySymptom柔虚症,Stasisofliverandinsufficientofspleen肝郁脾虚InsufficientQiofheartandliver心肝气虚InsufficientYangofspleenandkidney脾肾阳虚InsufficientYangresultininsufficientYin阳损及阴,61,62,63,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。OndiagnosisofpsychosomaticdiseasesinTCM,fourtraditionaldiagnoses,differentiationofdiseasesandsyndromesshouldbeinherited,andpsychologicalandphysiologicaldiagnosesinmodernpsychosomaticmedicineshouldbeabsorbed.TCMisidenticaltoWesternmedicineinphysiologicaldiagnosis.,64,5、病例CaseReport,65,CaseReport,Mr.Han,49y男，49岁Complaint:chestpainandtightnessfor3days主诉：胸憋胸痛3天,66,History:hecomplainedchestpainandtightnessfor3daysandfeltgraduallyseverebecauseofnervous.HewenttoahospitalsemergencydepartmentandwasnotexcludedofcardiacinfarctbyECG.Butlatercoronaryarteriographyshowednormalandnoevidenceofinfarct.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,67,Treatmenttosymptomswasnoteffective.ThedoctortherereferredhimtoourtraditionalChinesemedicinehospital.西医对症治疗无效推荐来我科看病,68,Exceptfortheabovesymptoms,t