Preliminary Study: Treatment Of Chronic
Emotional Disorders By Ultra-Low-Dose Steroid
Injection Of Outer Bladder Points 42-46
Peggy Finston, MD
Background A variety of acupuncture protocols are effective for acute emotional disorders; none are particularly helpful for those that are longstanding. Root causes of chronic emotional disorders differ, but all ultimately affect the flow of Qi in the Heart/Upper and Middle Burners. Specific internal energetic imbalances are reflected in specific external chest and abdominal muscle wall tension, including tension at the Outer Bladder points. Though named for mental/spiritual functioning, these points are not routinely used as a group to treat chronic emotional disorders.
Objective To evaluate the effectiveness of acupuncture to treat chronic emotional symptoms not controlled by pharmacotherapy.
Design, Setting, and Patients Four outpatients in the Western United States were observed in this study; they had chronic emotional symptoms that were resistant to psychotherapy and medications that put their jobs, family relationships, and other aspects of life at risk. All were willing to try an unconventional therapy for symptom relief.
Intervention Identification by palpation of tenderness of Outer Bladder points in the Upper Burner (BL 42, 43, 44) and Middle Burner (BL 45, 46). A subcutaneous injection of approximately .3 mL of 0.4-mg/mL triamcinolone was made to those points that felt like "knots" and radiated pain.
Main Outcome Measure Observation 30 minutes after treatment, with follow-up appointments and telephone calls over the next several months for self-report of symptoms and observation of signs of chronic emotional disorder.
Results Four of the 5 patients had decreasing intensity of target symptoms along with decreasing anxiety, and some were able to continue working or return to work. Some patients exhibited other signs, such as facial skin changing from splotchy-red to flesh tone.
Conclusions Symptoms of chronic emotional disorders were decreased significantly by injection of ultra-low-dose steroid into chest wall acupoints. Effectiveness may relate to restoring some energy balance and improving the outcome of an otherwise difficult-to-treat patient. Using both Western and Eastern approaches may be more effective than either alone.
Emotional Disorder, Outer Bladder Points, Injection, Upper Burner, Middle Burner, Acupuncture
Patients with severe mental disorders have few choices if medication and psychotherapy are ineffective.1 Electroshock treatment, vagus nerve implant/stimulation, and transcranial magnetic stimulation offer different strategies to improve mental functioning. However, they are expensive and the latter two are experimental and not widely available. Clearly, there is a need for other, less-invasive approaches for what psychiatrists term "treatment-resistant" disorders.
Eastern medicine provides a variety of acupuncture protocols that address emotional symptoms.2 Alone, they do not appear to have sufficient impact for those with chronic disorders. Modifications suggested by Chinese psychiatrists include increasing the frequency, duration, and number of needles used per treatment. Stimulation can also be augmented by adding moxa or electric current to needles or by substituting fluid injections and embedded sutures.3
Acupuncture points used vary, but certain ones appear more frequently in protocols for emotional disorders.2(pp197-280) Points can be local, in the scalp, or closer to the brain such as GV 20. But, mental functioning is not delegated to the brain alone as in Western medicine.
Body points are chosen for their effectiveness in diminishing common pathological patterns of emotional disorders such as LR 3 for Liver Qi stagnation and HT 7 for Heart Yin Deficiency. Also, somatotopes such as the ear and hand offer easy access to effective points.
In these protocols, the Outer Bladder points may be named as an individual point and used in combination with its Back Shu point partner such as Bladder 13, Back-Transporting Point of the Lungs, and Outer Bladder Point 45. But, the Outer Bladder points are not generally used as a group.2(pp228-230) This is notable, given that their names relate explicitly to mental/spiritual functioning and that clinically, imbalances in one mental function are usually found with imbalances in others. These Outer Bladder Points (located 3 cun from the midline, 1.5 cun from the Back Shu points for Lung, Master of the Heart, and Heart, Spleen, and Liver) are as follows.2(pp228-230)
- BL 42 – Po Hu translates "window of the corporal soul"
- BL 43 – Gao Huang Shu translates "incurable," and is also referred to as "happy point" due to its regulatory effect on Shen4
- BL 44 – Shentang translates "hall of the mind"
- BL 47 – Hunmen translates "door of the ethereal soul"
- BL 49 – Yishe translates "hut of the intellect."
History of Study
This study was prompted by serendipity. No longer able to tolerate psychotropic medications, a 40-year-old woman required electroshock therapy for psychotic depression with command hallucinations to kill herself. One month later, taking only zolpidem tartrate (10 mg), for sleep, she reported some improvement in mood, energy, and sleep, but continuance of auditory hallucinations, agitation, and nightmares. At this outpatient appointment, the patient also complained of flare-up of chronic right shoulder pain. On examination, her right upper back had several Ashi points, including right BL 42, BL 43, and BL 44. Subcutaneous ultra-low-dose steroid injections were performed on these 3 Outer Bladder points. Ten days later, the patient reported improved shoulder pain, along with disappearance of auditory hallucinations, nightmares, and agitation.
Over the next year, the patient had less severe relapses of depression, none serious enough to require hospitalization or electroshock therapy. (The auditory hallucinations returned but she elected not to have additional injections because, at that point, her fear of needles was greater.)
Four "treatment-resistant" patients were selected from an outpatient psychiatry practice. While targeted symptoms varied, all had conditions not responding to multiple medication trials. The symptoms were sufficiently severe to put their employment, family relations, and other aspects of life at risk. None had been helped by the addition of ear, scalp, or body acupuncture to their medication/psychotherapy regimen. All patients consented to treatment.
Identification was done by palpation of tender Outer Bladder points; patients sat upright, their shoulders curled forward to maximally expose the infrascapular area.4 Points were selected on their ability to radiate pain when pressed. Pain would "travel" such as through to the chest wall, down the back or arm. Frequently, these points felt like "knots." Sometimes, equally tender Ah Shi points were found at BL 46 or BL 47. These points were treated also. If both left and right points were extremely tender, both were treated.
An injection of ultra-low-dose triamcinolone (Lee T-N, SI 11 for chronic shoulder pain, personal communication) was given.5 The solution was prepared by removing .3 mL by syringe from a 10-mL vial of 0.9% sterile saline; .1 mL of 40-mg/mL triamcinolone solution was injected into this vial, yielding about 0.4 mg/mL solution of triamcinolone; 1-mL insulin syringes were used. Following palpation and sterilization of the acupoint, approximately 0.3 to 0.5 mL of solution was injected subcutaneously to create a wheal, approximately 2 to 3 cm in diameter. Patients usually received 3 to 4 injections per treatment.
The patients were observed over the next 30 minutes (during psychotherapy). Often, patients noticed increased relaxation by the session's end. Sometimes, the hue of their complexion shifted from red or splotchy red to more normal flesh tones, the timbre of their voice became less strident, and their gaze became brighter. Follow-up was conducted over the next 4-6 weeks by telephone and/or appointment.
There were no reports of dizziness or other short-term reactions. However, this solution, even at low concentration, can produce "divets," small indurated areas of muscle-wasting that take up to 2-3 months to heal and sometimes longer. This appears to occur more often in thin people and should be discussed in the consent process.
Case Report 1
A 29-year-old recovering drug addict was being treated for depression. Her new job, the first in 10 years, had initiated a non-stop thought process of failure ruminations that disturbed her sleep and undermined her performance during the day. This new symptom of her depression was not controlled by medication adjustments. Palpation revealed significant Ah Shi points on the right BL 42 and BL 45 and the left BL 42, BL 43, and BL 45. Following injection of these points, the patient's ruminations substantially cleared with only 1 treatment, and she has continued working.
Case Report 2
A 32-year-old man with depression and schizoid-like personality deterioration was unable to hold a job, maintain good relationships with his parents with whom he lived, and maintain a minimal standard of cleanliness and grooming. The patient received this treatment 8 times, approximately every 6 weeks. The points varied minimally at each treatment (left BL 42, left BL 47, and right BL 44). His depression improved, along with his general level of functioning. He has now worked at the same job for 2 years and is more communicative with his family. He reported that his thinking is clearer and he now has the ability to keep 2 or 3 tasks in mind at a time; thus, this ability helps his job performance. Mentally, he is more emotionally present and more spontaneous in speech and expression; his eyes are brighter and his gaze more confident.
Case Report 3
A 45-year-old woman had a 3-year history of increasing chronic neck pain and irritable depression. She was not sufficiently helped by trials of antidepressants, muscle relaxants, and narcotic analgesics, and her ability to continue working was threatened. The patient received 7 monthly series of injections and had significant improvement in pain and depression. She no longer takes antidepressants and has decreased pain medications by one-third.
Case Report 4
A 60-year-old woman with depression and chronic fatigue reported difficulty continuing to work due to fatigue. She was not helped by the 1st treatment and did not want to repeat it.
Chronic emotional disorders have many root causes, but all ultimately affect the Heart and Upper and Middle Burner. Matsumoto emphasizes the role of counterflow Qi in emotional symptoms when there is energy repletion in the upper body and vacancy below.6 Flow is frequently blocked in the two areas by a tight diaphragm. The disharmonies become tenacious because they are bidirectional and reinforce one another, i.e., many symptoms associated with counterflow Qi may be emotional, and emotional states themselves can engender that pattern.
Also, chronic emotional disorders result in phlegm, which then contributes to further imbalance.2(pp261-263) For example, in Soothing the Troubled Mind, the authors attribute schizophrenia to a "disharmony of Qi and Blood with phlegm and Fire harassing the upper body."3(p1)
While internal, these imbalances are reflected in the chest and abdominal wall musculature. One can palpate point tenderness of the Back Shu and Front Mu points and, as in this article, the Outer Bladder points. The patterns of tender points are related to the particular imbalance, an observation basic to acupuncture. The muscle tension itself likely reinforces this imbalance and contributes to the tenacity of chronic emotional disorders.
In the 1970s, a physician trained in Western medicine detailed the unusual and particular patterns of mostly abdominal and chest wall muscle tension related to different Western diseases. He treated these diseases by injecting small amounts of dexamethasone into the tight muscles (not necessarily acupoints), causing the muscles to relax and the symptoms to abate. His Western medicine-based hypothesis was that the treatment stimulated as yet unidentified somato-visceral reflexes between the organs and muscles.7
Perhaps it matters less how we explain this phenomenon than that we use it. Both Eastern and Western medicine acknowledge that different patterns of external muscle wall tension accompany different internal diseases or energy imbalances (although these last two terms are not interchangeable). Both also acknowledge that improvement and sometimes, cure, can be accomplished by relaxing the tension in the external muscle wall. In the East, acupuncture and moxa are used; in the West, steroid injection.
In this preliminary study, only the tender Outer Bladder points or the Upper and Middle Burners were treated, and yielded encouraging results toward decreasing chronic emotional symptoms. Even the small amount of triamcinolone used may help relax the muscle and facilitate the flow of Qi. The sustained stimulation created by acupoint injection "wheal," compared to that of a needle, may be necessary to get this improvement.
It is not clear why the last patient, #4, did not respond, and whether additional treatments might have been effective. One condition of effectiveness may relate to whether the emotional symptom was more likely due to Qi excess (patients 1-4) or Qi vacuity (patient 4). The injections may unblock excess Qi from the upper body to flow into the lower. This may not have been a palliative measure for the last patient. In future studies, more detailed assessment of each patient's tender abdominal and chest wall points may help define energy imbalances and the best circumstances for this treatment.
Symptoms of chronic emotional disorders were decreased significantly by injection of ultra-low-dose steroid into chest wall acupoints. The 3 to 4 injections were confined to the tender Outer Bladder points of the Upper and Middle Burner. Effectiveness may relate to restoring some energy balance and improving the outcome of an otherwise difficult-to-treat patient. Also, perhaps "treatment resistance" in Western psychiatry results from patients' entrenched energy imbalances that undermine any chemical "rebalance" with medication. Using both Western and Eastern approaches may be more effective than either approach alone.
- Kolb L. Modern Clinical Psychiatry. Philadelphia, Pa: WB Saunders; 1977:857.
- Maciocia G. The Practice of Chinese Medicine: The Treatment of Diseases With Acupuncture and Chinese Herbs. London, England: Churchill Livingstone; 1994.
- Dey T, trans. Soothing the Troubled Mind: Acupuncture and Moxibustion in the Treatment and Prevention of Schizophrenia. Brookline, Mass: Paradigm Publications; 2000.
- Matsumoto K, Euler D. Clinical Strategies in the Spirit of Master Nagano. Vol 1. Japan: Kiiko Matsumoto International; 2002:364-365.
- This author learned about intradermal injection of acupoints, with Ultra Low Dose Triamcinolone from Tsun-nin Lee, MD (San Francisco). He has treated chronic shoulder pain with only a single acupoint injection, SI 11. (see "Injection of Single Acupuncture Locus in Treatment of Posterior Shoulder Pain").
- Matsumoto K, Birch S. Hara Diagnosis: Reflections of the Sea. Brookline, Mass: Paradigm Publications; 1988:40-41.
- Edagawa N. The Treatment of Disordered Function From Pain to Sexual Complaints. Smithtown, NY: Exposition Press; 1987.
Dr Peggy Finston is a Psychiatrist and Associate Medical Director of Magellan Behavioral Health in Phoenix, Arizona. She specializes in the treatment of pain and emotional disorders by combining acupuncture and other alternative therapies with medication and psychotherapy.
Dr Finston's book, Parenting Plus, Raising Children With Special Needs (Penguin 1992), won a 1990 Presidential Award.
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