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musings on Yoga, Ayurveda and Chinese Medicine

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Depression and Inflammation

by Hyoun Bae on 06/18/18

Depression, Inflammation and Neuro-Immunology

I am as concerned about the rising status of depression in our society as the next. Providing effective care for those suffering with depression, through Chinese medicine, is a top priority.

Prof. Edward Bullmore of Cambridge puts forth some novel hypothesis around the role of inflammation in the causation of depression (Inflamed Mind, 2018). His recent work, meant for a popular audience, articulates the hopes for an emerging field – that of “neuroimmunology” – while highlighting the drawbacks of certain approaches to the care of major depressive disorder.

Bullmore tackles the mind-body problem, and the issues of characterizing depression as a disorder solely of the brain, or of being “in the mind alone,” as well as the limited success of treatment through SSRI’s. Each of these demonstrates a faulty or shadowy understanding of the mechanisms underlying depression.

He offers up flaws in our popular understanding of the blood brain barrier, which we have been taught to see as a “wall” between the brain and the immune system. The question of inflammation and it’s role in the causation of depression is also a glossed comment a broader inquiry into immunology. In addition, he also discusses in brief vagal stimulation as a potentially promising treatment consideration. Research in both areas can be appended to his general scope of argument, including our expanding understanding of the gut (microbiome) and the brain.

Main question – can we assume that inflammation underlies depression? For one, Bullmore notes that the diagnosis of MDD (Major Depressive Disorder) is challenged by comorbidity – that another, often physical disease may be present, one’s that may also involve inflammation.

Causation is difficult to prove.

He notes a number of instances such as the use of interferon, vaccinations and cites anecdotes where a rise in inflammation appears to correlate with depressive episodes. For many, the examples ring as common sense truth.

What a work such as Inflamed Mind offers is a glimmer of hope. We don’t find strongly, citeable evidence, but rather a window into a realm of hypotheses that asks us to widen our treatment considerations. Underscoring the role of social stress, its relation to inflammation and a potential relationship to depression, we again recognize the socio-cultural context of disease (156).

There are as of yet, no treatment options for really tackling depressive disorders with anti-inflammatory medications, nor clinical trials to back such approaches. Just as serotonin deficiency, tests for inflammation lack appropriate bio-markers that can be viably tested for. Bullmore makes this clear and simple for the reader.

These theoretical insights are perhaps best amalgamated into a clinical or therapeutic perspective that accounts for depression, along with other threads of causality to link valuable options. Prof. Bullmore is clear there is no panacea, and in talks online (youtube), we find ourselves looking as well at behavioral and more responsible approaches to self-care, absent of a distinct anti-inflammatory medication that will directly address the “inflamed mind.”

You will not find in Chinese medicine, a clear cut connection between inflammation and depression. In modern Chinese medicine, one might not extract a distinct model of causation that highlights the social context of disease – but rather, the clinical presentation, whose many shades lend to organic causes of disease.

In a way, zang zao syndrome or ‘visceral agitation’ is one reflection of mental-emotional disorders that maintain a distinct somatic causation, that mirror the notion of an “inflamed mind.”

Undoubtedly, we recognize stress and inflammation in ourselves and our clients, and in contemporary practice, along such findings as a dusky or dry red tongue, and clear signs of inflammation in the soft tissue.

I certainly agree with the implications of the author that we have to look directly at the rise of incidence of depression and alzheimer’s, through the lens of inflammation. I’ve genuinely emphasized the reduction of pro-inflammatory foods and lifestyle, for the long haul, as preventative measures. We often cannot foresee what illnesses will present, but we can take care of stress and better understand epigenetics.

Often it’s the perfect storm, that delivers the message of illness. We might simply do best to continually prioritize health, and make the healthier choices that are available to us.

Tongue Diagnosis: Body Mapping

by Hyoun Bae on 05/11/18

 

Among the most salient features of contemporary Chinese medicine tongue diagnosis is the topographic mapping of the body’s interiors upon the tongue surface. As if it is a diagram, we can look at the tongue body and coating and gather useful diagnostic criteria.

Again, two recently published tracts – one by Iannis Solos (Gold Mirrors and Tongue Reflections), include translations of two seminal texts, and another, a dissertation by Nancy Holyrode-Downing, explores the history of tongue diagnosis from the Han Dynasty to the present era. The former includes a variety of tongue images not commonly seen – both choose not to focus on the findings of a relatively recent and influential stream of knowledge from the Warm Disease (Wen Bing) current of Chinese medicine.

Two protagonists of this current of Chinese medical thought contributed much to our understanding of epidemic and febrile diseases. They are Wu Ju Tang and Ye Tian Shi – both of the Qing Dynasty. Perhaps what’s relatable here is that the Warm Disease school is associated with many of the heat conditions that we see in the warmer months, and which are particularly relevant to illnesses that occur from spring to late summer, including dermatological conditions, and dampheat lodged in the body’s interior.

 

Wu Ju Tong classified illness according to Three Burners – the upper respiratory, the digestive, and the urogenital. Of course, these are not their proper names for the upper, middle and lower burners.

If you look to a tongue, at quick glance you can divide the tongue body into three vertical sections, and narrow down pathology based upon what appears in those three divisions. If you notice chronic symptoms in the organs of a specific burner, you can see if you notice any changes in color or coating in one of those sections.

 

“Use herbs that are as light as the feathers of a bird for disease in the upper burner; use herbs to lift the Spleen qi and cause the stomach qi to descend in the middle burner, just like calibrating a scale that should always be in balance; and use heavy and cloying herbs to treat yin deficiency for the Liver and Kidney in the lower burner like adding a heavy weight to a scale to tip the balance.” – Wu Ju Tang

 

 

 

Ye Tian Shi offered a framework called the four levels, which reflects the impact of heat pathogens, often viral/bacterial in nature, upon the body dynamic. For those, the color of the tongue body and certain markings or presentations, alerts us to the severity of the disease transmission, and differentiating properly is a big deal as the nature of a pathogen is specified from the outset in Chinese medical diagnosis.

Actually, for quite a variety of skin conditions – such as eczema, psoriasis, dermatological presentations that involve macules, papules and blisters – this realm of diagnostic knowledge is indispensable. It’s common for a modern herbalist to view medicinals according to apparent pharmacological properties – such as antipyretic, antiviral or antimicrobial – without acknowledging how they function according to the extensive, empirical knowledge relative to, for instance, the stage of progression of such conditions.

There are very specific differentiations. A modern herbalist may lump herbs together, not knowing that herbs also harness the body’s intelligence into strategies; or paradigms of healing, perhaps. The outcome is that to the trained eye it’s like forcing break dancing to polka music.

Which brings us to consider the variety of information that these different texts and contexts have to offer.

In modern Chinese medicine, we regard the sides of the tongue as indicative of the state of the liver/gb, the tip and top 1/3 to the heart and lungs; the center to the spleen stomach and the lower 1/3 to the kidneys, large intestine, urogenital organs, etc. It’s not entirely clear when these derivations were solidified, but they have mostly been accepted.

·       In addition to these significations, we look to the color – color being a main indicator of the nature of imbalance. What would red signify – heat, generally. Pale color – a lack of blood or qi. A very common color is called ‘dusky’ – often regarded as purple, or pale purple and amounts to stagnation.

 

·       We also look at the size and shape. For example, puffy can sometimes imply dampness, or a lack of yang qi by which warmth is distributed. Sometimes the tongue body can be stiff, short, upturned, downturned, off to the side or quivering. These are all facets that we assess.

·       What about under the tongue? Distended sublingual verici often denote blood stasis.

·       What about the coating? Is it fresh, or perhaps dry or grey? Is the taste in the mouth sweet, sticky, bitter, or off? These are important indicators. A thin white coating is normal. Sometimes the body’s yin can be lacking and we see a geographic tongue, which is called peeled. There will be areas without coating.

I think this level of information can be had by searching the web, and can be useful.

The classics referred to in the above works hardly reflect any of these generalizations. They address specialist findings relevant to the school of Cold Damage, known as ‘Shang Han.’ Again, these translated texts were circulated around the 13th to 14th century flesh out tongue images that broaden the clinical presentations, for which pulse diagnosis and symptom/sign presentation were well-established.

What’s most relevant to these are specific stage-like presentations of acute, or chronic diseases noted in the earliest of Chinese medical lore. There is less of an emphasis upon specific organ systems, as the nomenclature and disease models are different in these contexts.

What you do find is a much more specific line of medical theory, which moreso, might indicate not that there is “dampheat in the liver/gallbladder (area}” and someone has been leaning on “food and drink,” but moreso about progression, i.e. whether a condition/individual would benefit from sweating (diaphoresis), or purgation, for example if heat is trapped in the body and can be evacuated down and out.

When speaking of external pathogenic factors – we rely on concepts of wind, cold, heat, dampness, dryness and fire – each of which have been treated from different medical models throughout the centuries.

So again, what we see in contemporary tongue diagnosis is the synoptic quality of body mapping, and we often take for granted how such images took on the interpretive significance we assume through modern, institutional learning. There’s so much wisdom packed into a generic imaging of the body that has to be astutely sifted through.

You can take things at face value, or recognize there are interpretive depths to just about anything – like routine bloodwork.

To respond to this question, what we can see from the tongue (or the pulse for that matter) can be rather nuanced, or quite generalized. Such is the beauty, or obscuring nature, of modern Chinese medical knowledge.

It all depends upon what you need to know, and how you are looking. Sometimes a quick review or glance is sufficient. Other times you are gaping at a tongue or pulse for a while, which can make some of my seniors or pediatric patients, giggle.

While tongue diagnosis is a part of the panoply of diagnostic methods, its also a window into the world of medicine, with superficial features and exteriors, as well as a rich and complex depths of inquiry and understanding.

Tongue Diagnosis in Chinese Medicine

by Hyoun Bae on 05/07/18

Tongue Diagnosis

“What do you learn from the tongue?” “What does the tongue inform you?”

 I commonly receive this question amongst new or inquisitive patients, and on occasion request that they examine the tongue to begin to make connections and better understand their health status. I recall my first notable presentation – my own tongue!

One celebratory evening, a colleague of mine of native descent invited me for dinner. After over a decade of very scrupulous vegan and vegetarian diet, I was offered food prepared after a hunt he and his relatives had gone on.

I obliged. And it was a personally meaningful and powerful exchange and experience, and I had a night full of vision-filled dreams. Though, when I woke up I also had a somewhat uncommon tongue presentation. The coating was black – seemingly dark and charred, a sign that might indicate heat toxin, or a type of toxic response, from the Asian medical perspective.

In actuality, we find many interpretive depths around tongue presentations, in clinical practice, and in the literature. What may be severe or illustrative in one context, may lack such significance in others.

 

Recent scholarly monographs (Solos, 2013), and a dissertation (Holroyde-Downing, 2017) we’ll review for you, explore the history of tongue diagnosis from the premodern era up until the present. One of the astonishing insights they provide is the historical development and inclusion of tongue diagnosis.

Among these textual/historical findings is the tracing of key passages from canonical literature such as the Inner Classic (Nei Jing), to the inclusion of diagnostic signs in texts on Cold Damage (Shang Han). We find that the tongue is associated, for instance, with visceral systems such as the heart (xin), but also in epidemic diseases due to external contraction.

Indeed, the author of Gold Mirrors and Tongue Reflections, a key translation of two seminal texts that are foundational to tongue diagnosis, reveals how contemporary interest arose with serious epidemics – especially around 13th century, and more recently – with the SARS epidemic that arose in the early 2000’s.

That epidemic diseases was a key force contributing to the focus on this form of “looking diagnosis” reveals how tongue diagnosis is especially helpful for understanding the progression of a disease process due to an “external contraction,” which we often relate to viral pathogens, and the like.

We gain a reflection of how a disease process is progressing, affecting the “interior” of the body.

What a tongue tells is context dependent.

We can look to a tongue and examine the “shen” which refers to the spirit, the liveliness or even constitution strength of the individual. This can be revealing also for prognosis. If the spirit is strong, and there is healthy sheen, the more superficial findings of the tongue can be seen as secondary – manageable.

In future discussions, we’ll highlight some cross-disciplinary and cross-cultural observations of the tongue. As with any diagnostic method, there is a great deal of interpretive variation. One might suppose that the canonical investigations should be at the forefront, and leave aside contemporary Chinese medical frameworks. But this could be delimitating.

Contemporary models can be largely reductive – or synoptic. They may gather information from disparate contexts to assemble an integrative tongue picture. In one context, such as fertility or dermatology – a clinician may pause briefly to examine key, relevant features that are significant to their discipline. In the case of epidemic diseases, the color of the tongue body, certain markings and the state of the tongue coat will take on another level of significance.

Lastly, from the cross-cultural perspective we can appreciate the tongue as a map of the body, with specific regions of the tongue relating to different organ systems, and that the tongue coating, emerging from the fluids of the stomach and as a mirror of the digestive system – these are almost universally similar.

So if we are examining the tongue, these are some of the principal features we are looking at: the overall appearance, the shape, the constitution, regional variations, coating and the colors that arise in these features that reflect different factors of imbalance, or reflect health!

More to follow in our newsletter and upcoming posts.

INSURANCE and CAP

by Hyoun Bae on 04/11/18



As previously notified, we will begin accepting out of network insurance – as requested by numerous clients over the years – by June 1, latest.  

For over ten years, we have offered sliding scale services through our Community Acupuncture Project. I know this has been a valuable follow up format, and low-cost healthcare option, for thousands of clients. We are still looking for other locations to maintain this service, but can refer you to three or so other Community clinics in the area, if these are more cost effective and appropriate routes of service for you.

Please do come in this last month for CAP. We will be on brief sabbatical, and to prepare for our service transitions in Mid May.

We will keep you posted on these options. It has been a commitment to serve seniors, students, underserved populations and to make services accessible and affordable.
With these changes, there will be amenable shifts in fee schedule.

·      Packages will likely be minimally increased.
·      We will no longer be offering sales and promotionals after June 1.

We kindly ask that all clients who are currently enrolled in a treatment package, to utilize remaining visits by the end of May.

We will be offering our last online sales packages, likely this month.

If you wish to make use of CAP, please do so by June 1, as the service will no longer be available at our Williamsburg primary office. We look to open another satellite, as we have in the past.
We’ll send follow up bulletins with our billing and insurance updates, but until May 15, we will continue as we have for the rest of the spring.
 
The fee for time of service payment for each treatment will remain. Invoiced appointments will be charged full for all services and adjunct modalities provided.  This applies for those patients that cannot pay the treatment service rate (cost of treatment) at the time of service. 
 
If we verify that your insurance does provide Out of Network coverage for acupuncture, we will submit our claims directly with your insurance company. If your insurance company refuses payment, you agree to pay the service fee for each visit that applies.
 
Patients will be responsible for any deductibles or copays that are part of their insurance coverage.




VERIFICATION OF OUT OF NETWORK INSURANCE COVERAGE
 
To begin this process (in May), you may kindly be asked to provide the following information:
 
Name
Address
Insurance Carrier
Member ID
Birthdate
SSN

Mindfulness and Trauma

by Hyoun Bae on 03/10/18

Mindfulness and Trauma

Trauma is ubiquitous in contemporary experience. 

We might not equate certain experiences as having been traumatic. Rather, we’re referring to the response of the bodymind, in general, to experiences that fail to be integrated and simply impact the way we implicitly move about, perceive and regulate intense emotions and stress.

In many cases, we just go on our way - that is adaptive intelligence, but I'd argue self-care should be ritualized, such that we consciously mitigate the impact of every day stress, as a measure of preventative care.

The impact of trauma is that it creates dysregulation of the nervous system. Mark Epstein, psychoanalyst and Buddhist contemplative, in a series of recent works (The Trauma of Everyday Life and Advice not Given), takes a look at the encounter of therapy and meditation, while narrating his growing intimacy with knowledge of trauma and its impact. In the latter, Epstein conveys a path of healing based on the therapeutic and transformative framework of Buddhism, within a psychoanalytic frame.

In his encouraging new work, therapist David Treleaven (Trauma-Sensitive Mindfulness 2018) explores ways that mindfulness can be adapted for trauma-sensitivity.

The evident truth this book advocates for are the needs for traumatic experience, and the understanding of individuals in a variety of social contexts, to be acknowledged when engaging mindfulness practice. Both therapy and mindfulness purport to uncover difficult and often unconscious material, for many, even short-term meditation may stir up or awaken us to parts of our experience that are less than comfortable.

The same may occur to us when we receive difficult news, are confronted with old feelings of abandonment, insecurity or blanketed pain – we might move into fight, flight, freeze or immobilization. Each of these presents a considerable sense of loss of control, what to speak of disengagement from the things we need to take care of, in the day to day. 

Having undergone a number of intensive, and even long-term retreats, I have limited knowledge of some perils that beginning and advanced meditators encounter. While most retreats have provided great insight, opening and much needed respite – meaning they promote personal growth, healing and transformation – I learned from them that they offer precisely what they claim. 

They are methods and technologies aimed at deconstructing limiting thoughts, habitual behavioral patterns, and releasing imprints of the past, that condition our way of experiencing in the present. 

Treleaven’s book offers some grounded appeals and guidelines for those who teach mindfulness to larger populations. I would agree that meditation instructors can benefit from therapeutic and neuroscientific insights, and that even traditional teachers can learn from these contexts. These insights can be instrumental to how we adapt meditation for our own healing, outside of retreat, when we apply meditation to difficult experience.

I’d also add that we as practitioners also need to learn more about these potentially unsettling experiences, and that traditional teachers and experienced retreat leaders (those with extensive long-term solitary experience) may have received unique training to counter these processes and struggles. 

Mindfulness, coopted for secular contexts, requires such contextualization, stripped from what Epstein highlights as Right View – which includes the type of perspectives that are beneficial at the time of traumatic upheaval in the contemplative encounter. The same goes for medicine and healing – including so-called healing crises or how we deal with anxiety, depression and trauma in acupuncture or herbal medicine. There is a view of therapeutic process. To just give pills, without insight and dialogue is more akin to contemporary psychiatric practice. 

Asian medicine always returns to the body, self-regulation and experience as it is to be engaged in therapeutic process.


 
Last month, the Veteran’s Health Administration published a document, expanding upon the welcome inclusion of more extensive and advanced acupuncture treatment for veterans and how acupuncture, and other wellness and integrative care strategies, can be covered for populations that would benefit from it. 

Mindfulness is also part of the expanding “tool kit.”

We share the same concerns for best practice, as everybody has experienced trauma, in different degrees. Others may have experienced emotional loss, early childhood shame from bullying, systemic racial oppression – but the imprints are similar. The mechanism of trauma is not only related to memory, but also regulation and integration.

These types of experiences can also come up in acupuncture, or yoga, and yet they present a new terrain of conscientiousness and learning, as we co-create novel approaches to care and healing.

What trauma research has shown is not so much the experience or circumstance, but how we responded and reacted to traumatic influences in the present – how we integrate through narrative and agency. The young and courageous survivors of the latest Florida school shooting tragedy reflect an act of resiliency we often do not see, but which is somewhat essential to more rapid and thorough recovery – the ability to speak, act and mobilize – in a manner in which the indelible wounds and emotional scars may be a source of strength, learning or appeased pain.

A traumatic imprint may be known or unknown, but rather than a rude awakening, mindfulness, yoga and acupuncture can be integrated into our therapeutic strategies, provided we engage practice skillfully.

Alaya 
Traditional Medicine Research Database