JOURNAL OF THE
INSTITUTE FOR TRADITIONAL MEDICINE
AND PREVENTIVE HEALTH CARE
Disease Prevention and Restoring Harmony:
Web Posting Date: May 2002
Key medical terms: cancer, depression, anxiety, neuropeptides, natural killer cells (NK), cytokines, cortisol, ACTH, DHEA
Key Chinese medical references: qi, shen, jing (three treasures), seven emotions, zang/fu, spleen, heart, yin and yang
Chinese traditional texts: Great Compendium of Acupuncture and Moxibustion; Canon of Medicine; Health-Preservation Skills Developed by Taishang Laojun; Golden Mirror of Original Medicine
Modern Chinese sources: Journal of Traditional Chinese Medicine; The Mystery of Longevity; Cancer Treatment with Fu Zheng Pei Ben Principle; Experience in Treating Carcinomas with Traditional Chinese Medicine
Traditional Chinese practices: tai ji, qi gong
SUMMARY: Emotional distress can contribute to the development of diseases; this has been known since ancient times in China. According to traditional texts, one can regulate the emotions and reduce their adverse impacts on health by following basic advice such as doing exercise, practicing temperance in eating and drinking, keeping a regular schedule, and pursuing mind-calming activities. Specialists in the field of calming the mind for health and longevity caution about egoism and pursuing too many personal desires; recommend finding constructive outlets for emotions--particularly anger; and emphasize the importance of developing an interpretation of one's life that focuses on becoming content, cheerful, and compassionate. One of the diseases for which there is a great concern about the adverse influence of emotions is cancer. Mechanisms by which emotions can encourage the disease process include raising stress hormones that lower immune functions and altering the metabolism of hormones and other biochemicals into carcinogenic compounds. Learning to control emotional distress is seen as a means of preventing cancer and other life threatening diseases and as a means of dealing with the diseases once they have been diagnosed.
DISEASE PREVENTION AND RESTORING HARMONY: CONTROL THE EMOTIONS
Most people recognize that emotional distress can contribute to disease. The emotions, or their immediate secondary effects--such as digestive stress and disturbed sleep--may weaken the body and make one susceptible to infection. The emotions may also trigger flare-ups of chronic diseases; many patients with autoimmune disease mention that this occurs after an emotionally stressful time. But, the question is, how to regulate the emotions so that resistance to disease remains strong?
This subject has been an important topic in the field of Chinese medicine. Since ancient times, disease causation was understood to fall into two major categories-external and internal. External causes included extremes of weather and the influence of pathogens, while internal causes were attributed to the emotions. Today, we recognize that emotions don't directly cause disease, but they make it more likely that a disease process will overcome the body's defenses and homeostatic mechanisms.
There are specific means of attaining balance and harmony that are incorporated into the Chinese culture, based on a long history of seeking good health and longevity. For example, the ancient classics suggest that one should:
Go by the laws of yin and yang, do body-building exercises best suited to one's conditions, practice temperance in food and drink, follow a regular schedule in daily life, avoid overexertion, and keep calm and cheerful.
Such suggestions may seem quaint in the modern world, but they are an integral part of the 2000-year-old culture that may have something to offer today, at least for those who are concerned about fragile health.
The Chinese descriptions of the effect of emotions on health rely on some terms that are not familiar to most Westerners. The main ones are:
These terms appear in descriptions of emotional excess and emotion-caused symptoms and diseases, and of their remedies that act by strengthening the body and calming the mind. As to strengthening the body, there are many methods, including proper eating habits, which will then help prevent emotional distress. Following is an explanation from Yang Jizhou in The Great Compendium of Acupuncture and Moxibustion (Zhenjiu Dacheng; ca. 1590), with a quote from an older Taoist source Daoyin Benjing:
The spleen is situated at the center of the five organ networks...It contains and fosters the five flavors, it brings about the five mental faculties, and it moves the four extremities....As soon as there is irregular intake of food and drink or overexertion of any kind, the spleen qi will be harmed....If we therefore force ourselves to eat when we are not hungry, the spleen will suffer. If we force ourselves to drink when we are not thirsty, the stomach will bloat. If we eat beyond capacity, the vessels in which the qi circulates will become obstructed, and the body's center (stomach region) will become jammed and shut off. If we eat too little, on the other hand, the body will become emaciated, the stomach will grow anxious, and our thoughts will become unsteady. If we eat contaminated food, the heart's ability to differentiate will become blurred, and we will grow more and more restless. If we eat things that we should not eat, the four great upheavals will occur and bring along disease. None of these types of behavior represents the way of good health. Therefore, it is most important to consume our food at the appropriate time, to drink our fluids in regular intervals, and to avoid both overeating and hunger pains. If we eat and drink according to these simple guidelines, then not only the spleen/stomach network itself will remain unspoiled and function perfectly, but also the organ networks will all be in a harmonious state of health.
An example of the Chinese approach to having a healthy emotional life is presented in The Mystery of Longevity by Liu Zhengcai, who begins by referring to the main text of traditional Chinese medicine, the Nei Jing:
The Canon of Medicine (Nei Jing) advises, in summing the experiences of centenarians in remote times: 'Do not be weighed down by perplexing thoughts; strive to be calm and optimistic; be complacent [calm in the face of situations that can cause anger]; keep sound in body and mind. This way, one can live to the age of 100.' The Canon of Medicine recognizes that emotional and psychological factors are important causes for illness. It indicates that excessive emotion impairs the internal organs of the human body. 'Anger hurts the liver, joy hurts the heart, brooding hurts the spleen, and melancholy hurts the lungs.' Hence, it proposes regulating the emotions by 'keeping the heart calm and cheerful and the mind free of worries.' 'Where can disease come from when the emotional state maintains inner composure?' Scholars on the art of healthy living in subsequent generations set forth many specific methods of maintaining optimism in accordance with this principle.
A good rendition of Chinese ideas of the dealing with emotions by calming the mind was presented by Yuan Liren and Liu Xiaoming of the Beijing College of Traditional Chinese Medicine as part of their series of articles on health preservation published in the Journal of Traditional Chinese Medicine. Their description of the nature of emotions and their depiction of traditional methods for dealing with the emotions is quoted here at length.
In traditional Chinese medicine, all such concepts as consciousness, feeling, and thought are referred to as shen, meaning mind, which is considered to be stored in the heart and to govern all the activities of the organism. Regulation by the mind is necessary in all physiological functions. In fact, the so-called three treasures [shen, jing, qi] are: mind, essence (which constitutes the material basis of the human body), and qi (which is the motive force of all life activities). A sound mind is considered the basis of health and longevity; similarly, scarcity of essence, deficiency of qi, and weakness of mind are the main causes of illness and aging. Since mind plays the role of governing life and commanding all the physiological functions of the primary internal organs and those of the rest of the body as well, it is easily depleted or impaired. Hence, taking good care of the mind is particularly important.
The activities of the mind can be classified into two kinds: emotional and mental. The former refers to changes of mood, known in traditional Chinese medicine as the seven emotions, i.e., joy, anger, melancholy, anxiety, grief, fear, and terror; while mental activities refers to consciousness and thinking. Since the activities of the mind are the general responses of the organs in conforming with the outside environment under the guidance of the heart, maintenance of the mind is bound to involve many aspects, which include roughly the following: preserving the tranquil mind, easing the mind, and regulating emotions. A brief account of these methods is given below.
Preserving a tranquil mind. Tranquil here refers to the state of mind being peaceful, tranquil, free from excessive desires and distracting thoughts, unaffected by outside changes. Such a state of mind will harmonize the organs and maintain a smooth circulation of qi and blood, benefiting the health. This consists of the following aspects:
Easing the mind. Moods are the responses of people to their surroundings, and everyone experiences the seven emotions and six desires [six harmful elements, described above]. If not properly regulated, the emotions will cause stagnation of qi and blood, and disharmony between the organs, leading to illness, even early death. Those who lived a long life, according to historical records, are almost all people apt to regulate their moods, the essence of which is to cultivate the mind with virtuous and elevated ideas and mold the temperament. Various methods have been developed and described by people in the past, which can be boiled down to the following: creating a happy mood by engaging in a great variety of carefree, light, and lively activities in which spirit is heightened, intelligence is increased, muscles and tendons are exercised, and circulation of qi and blood is activated so that health preservation is achieved in the midst of amusement and sports, achieving the aim of nurturing the mind, strengthening the body, and prolonging life. Some traditional methods employed for this purpose include taking up hobbies, such as playing the piano and chess; raising flowers, plants, birds, or fish; sightseeing; and chatting with friends.
Adjusting emotions. In one's daily life, the complicated situation is bound to influence one's moods such as from joy to anger, grief, etc. When one is in a bad or abnormal mood, one should try to adjust and control it lest it go to an extreme. As a mental means of health care, the following methods are used:
This summation by Yuan and Liu shows that one should respond promptly and effectively to emotional distress and should cultivate habits and thought patterns that help one avoid frequent experience of emotional excess. In the traditional Chinese medical view, the emotion-based causes of disease, like the external-based causes, are assumed to fade out as circumstances change. For example, for someone who is exposed to severe cold, which causes or contributes to some diseases, the weather in the summer will eventually turn hot and the initial cause will be removed, at least for a while. Similarly, if one experiences severe anger, fright, or fear, one will certainly experience something else later. Rather than waiting for circumstances to change gradually, one can more immediately respond to the situation, for example, by warming up the body after exposure to extreme cold or relaxing anger after a threatening encounter.
There can be circumstances where causative factors remain prevalent, but this is usually because of failure of the person to accept and follow the basic rules that have been developed over the centuries. If one lives in a region of the country where the weather is cold most of the time, then one is expected to adapt to this circumstance by dressing warmly, eating warming foods, and staying physically active. If one experiences anger or other emotion repeatedly, one is expected to adapt to the circumstance by altering behavior and changing attitudes. For the Chinese, the changes are made in accordance with one or more of the traditionally provided means of accomplishing the task: Confucianism, Taoism, and Buddhism. These philosophical and religious systems (often referred to as the three pillars of Chinese society) instruct people in living properly. In the West, many people turn to Eastern philosophy for assistance in this realm. Still, people often feel most comfortable discussing the issue in terms of health and not in relation to the religious and cultural peculiarities of the East.
Shi Tianji, a scholar on the art of healthy living in the Ming Dynasty, proposed 'Six Always' for maintaining a calm and cheerful state of mind, summarized here:
Thanks to the availability of translated books, Westerners have relatively easy access to these Oriental traditional systems of dealing with emotions; additionally, they have other means of dealing with emotions, including their own religious heritage and established psychological aids.
SUMMARY: THE CHINESE METHODS FOR DEALING WITH EXCESSIVE EMOTIONS
Chinese literature describes two basic means of dealing with excessive emotions:
APPENDIX: How Emotions May Contribute to Cancer
The traditional Chinese medical view of cancer etiology holds that there are several possible contributing factors, and that one of the principal causes is internal factors, namely emotions. For example, Sun Binyan writes in his book Cancer Treatment and Prevention (1):
According to our understanding of the tumor patient, most have suppression of the emotions. They tend to hold in their anger. Although some patients have good results after treatment, emotional stimulation may cause them to decline again and then the previous treatment would have been in vain. Some people have a severe phobia about cancer. Before they know the real disease, they have a lot of suspicion. Once they know they have the cancer, their whole spirit breaks down. This kind of spiritual state is very bad for the treatment.
In the book Prevention and Treatment of Carcinoma in Traditional Chinese Medicine (2) Jia Kun gives 10 recommendations for prevention. In addition to good environment and personal hygiene, proper levels of work (exercise) and rest, good eating habits and proper food, avoiding smoking, and timely treatment of all ailments, he states that:
Emotional changes, such as worry, fear, hesitation, anger, irritation, and nervousness should be prevented. Mental exhaustion is harmful and life should be enriched with entertainment.
Shi Lanling and Shi Peiquan mention the etiology of various cancers in their book about Experience in Treating Carcinomas with Traditional Chinese Medicine (3), as regards the effect of emotions:
The etiologic factors of the disease involve chiefly the disturbance of the seven emotions, especially melancholy, anxiety, and anger, which are liable to impair the spleen and the liver. Impaired by melancholy and anxiety, qi will be stagnated and the spleen will lose the function of transformation and transportation, leading to disturbance of water metabolism and the subsequent accumulation of phlegm-dampness, while, impaired by anger, the liver qi will be stagnated. The stagnated liver qi, as qi is the commander of blood, may give rise to blood stasis if not relieved in time. Thus, emotional disturbance, in-coordination between the ascending-descending movement of qi of the internal organs, sluggish flow of qi and blood, and the ensuing obstruction of dampness, phlegm, and blood stasis are the fundamental pathogenesis of the disease.
The authors go on to mention other contributors, such as consumption of food that is "rough, hot, or hard," indulgence in smoking, alcoholism, traumatic injuries, and chronic ulceration. In their section on treatment of breast cancer, the authors refer to a discussion in a Ming Dynasty text by the surgeon Chen Shigong (1555-1636 A.D.) indicating that breast cancer "results from anxiety, emotional depression, and overthinking which impairs the liver, spleen, and heart and causes the obstruction of the channels." This text is also mentioned in The Treatment of Cancer by Integrated Chinese-Western Medicine (4), translated this way:
Breast cancer is due to worry and melancholy. Lots of ideas hanging around make one feel dissatisfied. Perverse flow of liver qi to the spleen leads to the obstruction of the channels and collaterals and congealations due to excessive accumulation.
Pan Mingji, in his book Cancer Treatment with Fu Zheng Pei Ben Principle (5), presents a section on etiology of cancer, listing 5 contributing factors. The first item mentioned is emotional disturbance:
TCM embodies changes of spirit and sentiment as the seven emotions: pleasure, anger, grief, fear, yearning, sorrow, surprise, all of which are emotional, physiological reactions of an organism towards external changes in its environment. Emotional disturbance refers to reactions, either excessive (excitation) or insufficient (inhibition) which will ultimately lead to disturbances in the flowing of qi and blood and the visceral functions, with subsequent illness. TCM claims rage harms the liver, excessive stimulation harms the heart, grief harms the spleen, great sorrow harms the lungs, and fear harms the kidneys. Though not necessarily precise, this belief definitely points out that emotional injury will effect the physiological functions of the qi, blood, viscera, and channels, and lower the body resistance, resulting in disease. The human body is susceptible to cancer when under emotional stress or disturbance. This is mentioned early in Chinese medical classics, such as Yellow Emperor's Canon of Internal Medicine and Golden Mirror of Original Medicine.
The Oriental view that emotions contribute to cancer formation differs from that adopted by Western scientists, who regard cancer as a change in DNA that is induced by a chemical agent, radiation exposure, or insertion of viral genes (in a few cases, the abnormal DNA may already be present in the genetic heritage of the individual). In order for the induced DNA change to lead to cancer, it is first not properly repaired by certain DNA repair proteins and then the abnormal cell is not destroyed by a natural cell death process (apoptosis). Cancer initiating factors act within the environment of the individual-which includes the person's genetic background and nutritional status-to trigger the development of cancer. Thus, lung cancer is often caused by breathing carcinogens such as those contained in cigarette smoke; stomach and colon cancer are often caused by carcinogens in the food supply; skin cancer may be induced by excessive exposure to the ultraviolet light of the sun; and leukemia may be induced by exposure to industrial chemicals, to radiation, or to a virus that resides in the bone marrow. Traditional Chinese doctors were aware of this type of external causation. For example, they recognized that cancer occurred more often in certain places and was attributed to something in the drinking water, or that cancer could be induced by rotted food and, in modern times, by smoking. Yet, it was the emotions that were often regarded as the most significant factor. At the least, the excessive and/or suppressed emotions would disrupt the functions of the internal organs and the flow of qi and blood, and then the external factors would more easily induce further damage. Pan goes on to say:
There are a lot of factors which affect the anticancer ability of the organism, but the leading one has to do with whether the spirit, nervous system, and various defenses of the organism are perfect. A lot of evidence proves that those who are optimistic and undertake exercises [in China, this refers mainly to taiji and qigong, along with similar types of practices, as well as hiking in the woods] tend to have healthy and sound function of the nervous system, strong physiques, and naturally great anticancer ability and immunity. Even if those people come into contact with outside carcinogens, they will not develop cancer. On the contrary, those who have mental injury, who are disheartened, or often have a fear of cancer, and who do not undertake exercises at all or are overtired, whose daily life is irregular and unsanitary, whose spirit and nerve function is disorganized, tend to reduce their defensive ability. As a result, the rate of cancer occurrence among those people is higher.
Western researchers have not undertaken detailed study of the possibility that persistent or repeated experience or suppression of emotions contributes to the risk of cancer for several reasons. Aside from a low motivation to undertake the study because other factors are considered more important, such research is extremely difficult to perform properly. One would have to recruit a very large number of people into the study, have some reliable method of measuring emotional status over a long period of time, and then find some way to quantitate the emotional condition (as it varied over time) so as to compare with the actual incidence of cancer among individuals under study. Still, the fledgling field of psychoneuroimmunology (the study of how psychological states and nervous system manifestations of the emotions impact the immune system) has developed some data supporting the concept that emotional stress increases a person's susceptibility to cancer (12).
In China, a study (7) involving a huge population (750,000 people in Beijing) attempted to find out if psycho-social factors contributed to the incidence of primary lung cancer. They reported that their study showed three factors positively associated with occurrence of lung cancer:
Poor relationship with coworkers would generally suggest that there is emotional tension during the work day, so all of these could indicate emotional disorders associated with higher incidence of cancer. When "depressive feeling for a long time" was analyzed further, it was found that this was a significantly stronger risk factor for women than men. This study supports the traditional Chinese contention that emotions can contribute to cancer incidence, but it would need to be verified by a tightly controlled trial in order to convince Western researchers that the results could have important implications for understanding the etiology of cancer.
The emotional status of patients after receiving a diagnosis of cancer has been studied, but the difficulty in monitoring emotional status was perhaps the only thing clearly revealed. In a study conducted in Denmark (6), women who had just been diagnosed with breast cancer that was considered to have a low risk of recurrence (easily treated, not metastasized) were compared with women from the general population. The results conflicted with the expectation that the patients would have a higher level of stress and anxiety, but this may simply reveal the difficulty of designing the monitor of emotional status, since other studies have found that anxiety and depression in cancer patients tends to be a significant problem.
A POSSIBLE MECHANISM INVOLVING SHORT-TERM EMOTIONAL STRESS
The Chinese physicians who comment about the role of emotions in cancer formation point to the fact that the internal viscera become weakened, thus increasing the opportunity for pathologies of all types, including cancer. Western research has already supported the idea that depression can impair immune system functions (perhaps indirectly, such as by repeatedly impairing a good night of sleep, with sleep contributing to maintenance of the immune system). It has been shown that tumor-relevant lymphocyte subpopulations, such as natural killer cells (NK cells; these can directly attack cancer cells), have receptors for various neuropeptides, including those released during stress. This finding indicates how NK cell activity might be modulated by a person's emotional responses. The level of NK cell activity has been found to be a reasonably good predictor of outcome for women with breast cancer. Further, a portion of the loss of this immune cell activity in cancer patients was shown to be correlated with psycho-social measures such as patient "adjustment" (avoiding showing distress at the cancer diagnosis/treatment), lack of social support, and symptoms of fatigue/depression (14).
Along these lines, the immune system may regulate the activities of enzymes, such as aromatase, that converts estrogens to estradiol in breast tissue (17, 18), where estradiol is thought to contribute to breast cancer. Cytokine changes (as occur with infection and inflammation) have been observed in cases of major depression, and have been suggested to be a potential cause of depression (19, 20). In fact, some antidepressant drugs are tumor necrosis factor (TNF) inhibitors; this being one of the cytokines that causes considerable adverse effects in cancer patients. It is also possible that depression, and other emotional disorders, will affect the cytokines.
In the book Why We Get Sick (10), which is based on the premise that most of our body (and mental) functions have been determined by evolutionary factors, the author explains how a potentially helpful feeling (anxiety) can have harmful physiological effects:
Everyone must realize that anxiety can be useful. We know what happens to the berry picker who does not flee a grizzly bear, the fisherman who sails off alone into a winter storm, or the student who does not shift into high gear as a term-paper deadline approaches. In the face of threat, anxiety alters our thinking, behavior, and physiology in advantageous ways....Because anxiety can be useful, it might seem optimal to adjust the mechanism so that we are always anxious. This would be distressing, but natural selection cares only about our fitness, not our comfort. The reason we are sometimes calm is not because discomfort is maladaptive, but because anxiety uses extra calories, makes us less fit for many everyday activities, and damages tissues. Why does stress damage tissues? Imagine a host of bodily responses that offer protection against danger. Those that are "inexpensive" and safe can be expressed continually, but those that are "expensive" or dangerous cannot. Instead, they are bundled into an emergency kit that is opened only when the benefits of using the tools are likely to exceed the costs. Some components are kept sealed in the emergency kit precisely because they cause bodily damage. Thus, the damage associated with chronic stress should be no cause for surprise....In fact, recent work has suggested that the "stress hormone" cortisol may not defend against outside dangers at all, but instead may mainly protect the body from the effects of other parts of the stress response.
Thus, if the "emergency kit" that is intended to respond to specific immediate dangers is left open for an extended period of time, for example, by living in a situation that the body and mind deems unsafe, then progressive damage to the tissues can occur. This damage may then cause or exacerbate chronic disease or a life-threatening event (e.g., stroke, heart attack, incurable cancer). Cortisol, which may act as a protector for the body, when elevated for long periods of time, can impair immune functions, eventually leading to damage.
Chinese researchers have attempted to quantify physical responses to emotional distress. In one study (21), rats that became angered and fought with one another were tested after this change compared to others that remained in a calm condition. The study results suggested that the stress condition induced release of extra adrenocorticotropin hormone (ACTH), raising cortisol levels, which had a secondary effect of reducing the output of hydrogen peroxide from macrophages (a type of white blood cell). It was thus proposed that the defensive function of the immune system could be slowed or impaired as a result of the emotional stress. In an Algerian study of women under stress (22), it was shown that heightened cortisol levels often occurred, and that this was sometimes counteracted by production of another hormone, dehydroepiandrosterone (DHEA), which was suggested to be a potential therapeutic substance to counter the adverse effects or raised cortisol.
It seems entirely possible that a single period of intense stress lasting months, such as occurs with a divorce, death of a family member, loss of job, or other life-changing event, rather than decades of habitual emotional distress, might lead to serious damage to the tissues which could trigger or allow the development of cancer. The stress hormones might themselves stimulate latent cancer cells into reproduction; the hormones or their metabolites might transform a normal cell to a cancer cell; or the damage to the tissues may lead to failure of normal cancer-control mechanisms. In this way, a diagnosis of cancer may be encountered a year or two after such an event (it takes that long for the cancer to develop enough to yield evident symptoms or a diagnosable lump). Such a correlation-between stressful events and subsequent cancer diagnosis (13) or recurrence of previously treated breast cancer (15)-has been supported by early studies that still require replication. If severe emotional stress (of the type that is likely to be mentioned during questioning) does sometimes give rise to cancer soon after the stress is experienced, this would certainly explain the observation made by traditional practitioners: that emotions are a cause of cancer.
REFERENCES TO APPENDIX