Diagnosis and Treatment of Depression in Chinese Medicine and Acupuncture - Part 2: Clinical Practice

Case Study

A 43-year-old woman.

Arrived at the clinic with a primary complaint of prolonged depression and anxiety lasting ten years. Diagnosed and treated by a psychiatrist, taking fixed dosages of Effexor and Cipralex.

Prominent clinical symptoms: deep difficulty in daily functioning, chronic fatigue and exhaustion, muscle pain and stiffness, chronic constipation, spontaneous sweating, loss of appetite, tremors, dizziness, headaches. Unemployed, low functionality.

Ten years ago she experienced a significant loss in her life. Since then she has struggled with significant functional difficulties, accompanied by sadness, weeping, and constant grief. Throughout this period she has been under the care of a psychologist and psychiatrist with ongoing pharmaceutical treatment in steadily increasing dosages, which according to her assist slightly with physical functioning but fail to alleviate her mental state.

She is a sensitive, talented woman with high expressive ability and a desire, in her words, "to do something meaningful in life." She presents a consolidated personality that knows how to express herself and articulate her desires, yet these do not align with practical functioning and the actions required to realize them in daily life. Looking toward the future causes her great anxiety.

Primary Element: Yin Water

She belongs to the Yin Water element, the deepest expression of Yin within the Five Elements framework. This is the direct connection to a person's primordial potential: self-will, calling, and the inner memory of who I am. The entire system is Yin: a general tendency toward inward gathering, delicacy, sinking into a diffuse inner world, difficulty in realization, and deep identification with feelings over action.

Among patients identified with Yin Water, there is often significant difficulty in mobilizing internal movement outward. They move easily between layers of awareness, intuitive wisdom, and emotional depth, yet all these frequently remain trapped within the boundaries of the body and closed existence. The sensation "that the body betrays and fails to respond," as she described, embodies the gap between deep inner knowing and actual dysfunction, a gap that generates an experience of self-alienation.

The soul seeks realization, but physical, emotional, and functional tools are unavailable, or their usage leads to extreme exhaustion. Thus a familiar dynamic of deep depression takes shape: a genuine desire to live with meaning, contrasted against a sense of loss, loneliness, and an unbearable gap between the idea of life and life itself.

Relationships Between Water, Metal, and Wood

Because of the strength of the Metal element in her system, Metal nourishing Water, all expressions of the Water element receive a strong push in terms of values, laws, definitions, and focus, where the leading drive is a need for aesthetic and formal perfection, with defined, fixed values. Here exist opinionatedness, criticism, morality, and judgment toward every external matter, another person, and above all toward herself. The aspiration for perfection represents the unbearable distance between the ideal and life itself regarding realization, and this gap torments her, preventing her from stepping into action.

The Wood element, which ought to receive nourishment from Water and bring potential into execution, receives no support, operating instead from a destructive stance toward the Water element. Thus a blockage is created: the conflict between knowing and feelings on one hand, and daily realization on the other, gives birth to an overreaction, disproportion in communication, frustration, anger, and impulsivity.

She struggles in relationships and in expressing emotions that expose vulnerability, as the Yin Water element is inherently fortified, fearing intrusion, intervention, and change. When the Water element fails to nourish the Wood element, a blockage in communication becomes evident, expressed in a lack of proportion between what she wished to say and the intensity, impulsivity, and anger that arise from the fact that her Wood element destroys her Water element. In such a state, there is a tendency to react before thinking, jumping into hasty action before an idea has crystallized, and offering disproportionate spontaneous reactions.

Yet alongside all this lies a deep yearning for connection: the need to be understood, included, loved, and to find a place where one can simply speak and exist distinctly. But the path there feels nearly impossible, for the fear of harm, weakness, and exposure is stronger than she is. She adopts a familiar strategy: hiding behind logic, intellectuality, criticism, and a highly developed sense of justice, building a system through which the mental side dominates and conceals the emotional.

For many years she has lived with feelings of guilt and unworthiness, constantly criticizing herself, and at times acting against herself to "prove" she is undeserving. When she does attempt to act, it crumbles: her body aches, thoughts confuse, exhaustion mounts, and she drops back into bed, waiting for another day when she might be able to move and act, but meanwhile she weakens. Regarding Metal-Wood relationships, an appropriate model of restraint exists, but the Metal element is overly strong upon the Water element (over-nourishment), and her Wood element destroys her Water element (Destructive Cycle). These two press upon Water from both directions, preventing the Water element - the primary element - from achieving a flowing, balanced expression.

Relationships Between Water, Metal, and Earth

It is precisely the excess of Metal that creates many difficulties for her, because in her system the Metal element destroys the Earth element, which is her weakest element. The built-in lack of Earth creates a structure that is initially not highly stable, making her prone to frequent instability and fluctuations, which triggers an obsessive search for stability due to its prominent absence.

Her nutrition is poor, primarily due to loss of appetite stemming from prolonged depression, and attempts to fuel the system occur through carbohydrates and sugars. She describes herself as not hungry throughout the day, yet suffers from nocturnal binge eating, bloating, gas, chronic constipation, and abdominal pain: clear signs of Dampness and Damp-Heat, the byproduct of Spleen weakness and stagnation. She sleeps most of the day, stays awake at night, suffering from dizziness and a sense of instability.

Fatigue, mental cloudiness, emotional apathy, and relinquishing action all testify to a Spleen empty of Qi. The diagnosis points to a clear Blood deficiency, even if not expressed in Western blood tests. The Lungs, which also suffer from heavy smoking, fail to distribute Qi properly, and Wei Qi weakens.

An excess of the Metal element over Earth places values and rules ahead of feeling and personal nurture. She experiences no sense of belonging, feeling distance, rejection, and a lack of self-meaning that occasionally alternates with feelings of arrogance and superiority, living between two poles that tear her personality apart. She tends to pre-emptively dismiss any possibility of belonging, partnership, or starting a family, yet simultaneously admits that this is precisely what she yearns for. This is the paradox of an overly strong Metal element setting excessively rigid boundaries for delicate, sensitive Water.

When the Earth element collapsed - that Earth which was already weak - a widespread collapse occurred across all domains. The Yin Water element, by nature, tends to yield power to others: relationships, family, work. The security of the Water element is derived from without, as that is what connects it to the here and now. The loss she experienced ten years ago represented a pillar, belonging, and a connection to the here and now through emotional and financial support. When that collapsed, she found herself lacking in areas far broader than coping with grief, faced with the need to rebuild herself on her own without possessing the will to do so.

Relationships Between Water and Fire

The axis between the Water element and the Fire element is one of the most central and sensitive axes in psychological treatment. This is an axis concerned with consciousness, awareness, and a person's capacity to comprehend and internalize life experiences, whether raw emotions or abstract thoughts through heart and mind. It expresses the movement from potential to fulfillment, from the deep quiet of Water to the expanding expression of Fire. This is, in many respects, a person's awareness axis, ultimately expressing communication with oneself and the world.

In her case, as someone born with the Yin Water element, there is an excess of Fire that insults Water and distorts the relationships between desire and fulfillment, communication and vitality, aspiration for potential and actual emotional realization. This points to idealization and illusion in the perception of life, as yearning Fire seeks an escape from the mental pain of Water.

Excess Fire brings constant Qi stagnation, Damp-Heat reaching the Heart, and unregulated emotional heat, creating states of confusion, hallucinations, insomnia, and extreme transitions between inner drama and outer expression. She is prone to bursts of speech and emotion that initially appear liberating but end in exhaustion, collapse, and a feeling of emptiness. At times she says she has "lost her voice" or has "nothing to say," not because content is lacking, but because she cannot connect to it in the moment or understand what she truly feels.

The result: a wave of turbulent, unrestrained emotions, accompanied by palpitations, constant tension and pressure in the chest area, sudden weeping, rage attacks, and chronic anxiety reaching temporary mania. Following such an emotional peak comes a crash: an "extinction" state where speech virtually vanishes, exhaustion mounts, and the body asks only to rest or sleep. Because of the strength of her Metal element, she manages to project an outer facade of relative restraint and control. This is a deceptive mask, concealing clear lines of suicidal talk and extreme thoughts.

Relationships Between Metal and Fire

Metal insulting Fire creates a pattern where the response to emotional distress is cold detachment rather than emotional processing. Instead of feeling and containing, she flees to thought, order, and an overly logical solution to a problem that is essentially emotional. Excess Fire, as it appears in her case, also generates momentary narcissistic thoughts and an illusory sense of elevation, but all these dissipate quickly, replaced by a sharp plunge, emptiness, or a sense of worthlessness.

Treatment Strategy

The strategy in this case may appear complex because all Five Elements are involved, but precisely here lies the advantage of the Five Elements approach: it is not engaged in chasing symptoms, but in finding a clear, authentic starting point from which genuine change can be mobilized.

In her case, the starting point is clear: the Yin Water element. This is her primary element, upon which her inner identity rests. Therefore, every therapeutic intervention, even if directed at severe symptoms (anxiety, exhaustion, sleep disorders, loss of appetite), must account for the inner position of this starting point, even if currently weakened, blocked, obscured, or inaccessible to herself.

Strengthening the Water element is the most necessary action, yet there is no point in doing so directly and aggressively before treating what interferes relative to dispersion: the Wood element, the Metal element, and to a lesser extent the Fire element.

Usually, after several treatment sessions, as the connection builds, as body and mind are treated, and as the patient begins to express herself, she senses that someone truly sees her, creating relief. This is the moment when one can begin establishing the root, gently strengthening Water, and guiding internal balance according to element relationships rather than solely by symptoms. It is a journey toward restoring balance.

Treatment order: strengthening the Water element; strengthening the Earth element (draining Phlegm, nutrition); regulating the Fire element (primarily treating the Heart [HT] and Pericardium [PC]); treating the excess cycles.

I do not push a patient to evolve, but I encourage them to do so. I do not stop pharmaceutical treatment, nor do I recommend stopping therapy with a psychologist. I concentrate on my work and make every effort to bring awareness and relief with proven improvement. Once acquired, the patient decides and consults on their own with a psychiatrist regarding their medication dosages.

In every treatment session, I allocate time for conversation, self-awareness, and sharing in the process. Emotional suffering can be relieved and treated with the right approach and mutual willingness from both sides.

After a period of treatment, I expect only one thing from my patients: taking responsibility for themselves. And I will help them with this and stand beside them.

In this case, significant improvement was achieved, deep change was evident, and pharmaceutical treatment was reduced almost entirely. About four months of treatment addressed the root rather than merely symptoms, creating new ground for growth.

Always and in every treatment, the pulse picture determines how I act. It guides the choice, clarifies possibilities, points to the depth of pathology, the required timeframe, and progress in treatment. Therefore, I tend not to dictate acupuncture points: there are endless possibilities, shifting from session to session.