Song and Depression – The Significance of Chinese Medicine Theory on Psychiatric Diagnosis
The Third Hospital of Chaoyang District, Beijing
Singing and music are easily associated with laughter, singing and dancing. Does this have anything to do with psychiatry? The following is some clinical experience on the relationship between song and depression.
I. Musical expression and psychiatric symptoms
Normal people can use music to express their mood, and patients with mental illness can choose music as well. Patients with manic episodes often show thought association disorder, shift with the situation, high emotion, increased behavior, and often sing a song because of their good mood. Ming? Sun Yikui, “Medical purpose xuyu? Epilepsy: “The maniac is also known as rampant madness. It is said that the onset of the disease, rampant and just violent, as in the “treatise on typhoid” Yangming big actual frenzy, cursing and insulting without avoiding relatives, and even climbing high and singing, abandoning clothes and walking, over the wall on the house, holding a knife and stick, more than day and night, sex is laughing, disobedience is angry, if the evil attached to the person is also.” Here, the song reflects the high mood of the patient. In addition to the performance of singing while ascending to a high place, more importantly, the typical manifestations of mania are the irritability of laughing when one is sexually attracted and getting angry when one is disobedient.
Emotionally rich people tend to use songs and zither to express their mood, and when they are in a good or bad mood, they can often hear it from the songs and zither, so there is the ancient saying of “knowing the voice”. We are not music professionals, may not be able to hear different players in the same piece of music to express different emotions. For people with strong emotional changes, their emotional changes will be different in the choice of songs and music. The songs chosen by manic episode patients are usually high, warm and fast-paced, while the songs chosen by depressive episode patients are often low, sad and long. Of course, these are only when the patient’s symptoms are more obvious. Patients with mild symptoms may only show prominent changes in one or two internal organs, but if the patient’s symptoms continue to worsen, the lesions may involve multiple internal organs, and the performance will often be confused or distorted due to the aggravation of symptoms. For example, a manic patient may show symptoms of shouting, singing, laughing, crying, etc., while a depressed patient may show symptoms of silence and inactivity or even impulsive killing.
Singing can also reflect the condition of one’s internal organs, which is helpful in determining the deficiency of yin and yang and the strength and weakness of the internal organs. Tai Qing Shen Jian? Volume 4? On the sound” said: “human nature moved in the heart and the shape of the sound, so the sound of the gas is hidden. Gas structure of the void and into the sound, inside to convey the intention, outside to respond to things. …… God is clear and gas, the sound is warm and smooth and round. God turbid gas, the sound is anxious and light hissing. …… is to God in the internal and gas and outside, the sound is safe in terms of sequential order, there is no change of color. If the God is restless, must not and gas, then its words are out of order, drunken color mixed wrong, are also the villainous thin phase …… people endowed with five elements of the form, its voice also has five elements of the image. Therefore, the wood sound high and smooth, fire sound anxious, gold sound and moist, water sound round urgent, earth sound sunken thick. If the form and the shape of the birth of the auspicious, the phase of grams is bad.”
The above-mentioned song refers to the patient’s symptoms that are active due to the change of emotion. And when the singing voice appears in other ways, it may be different.
Second, musical hallucinations
When diagnosing a mental illness, the first step is to make a symptomatological diagnosis. When we have collected the information, we have to determine which part of the cognitive, emotional, and volitional behavior is impaired and what kind of nature of the problem. Disorders of cognitive processes are one of the most prominent problems in psychiatry, especially in severe mental disorders. The most commonly recognized symptoms of cognitive disorders include, sensory disorders, perceptual disorders, thought association disorders, and thought content disorders. Perception is the brain’s reflection of the overall properties of objective things that act directly on the sense organs. Hearing a sound is a sensory process, while recognizing what is heard is a perceptual process. The most common perceptual disorder is phantom hearing. Phantom hearing can provide much help in determining the nature of the disorder and ultimately the diagnosis. We need to make a comprehensive judgment based on the symptoms, but sometimes there are difficulties, so a refined analysis of the symptoms is of great interest.
Hallucinations are illusory perceptions and are a common symptom in psychiatric patients, especially in schizophrenia, but also in manic episodes, depressive disorders, organic brain disorders, and other diseases. Early hallucinations may be small and monotonous. As the course of the disease and the development of the disease, verbal hallucinations may appear, the amount gradually increases, the content gradually enriches, and the patient may be affected by the hallucinations to produce some emotional and behavioral abnormalities. The causes of hallucinations include psychological factors, such as excessive mental stress, disease in a part of the body, auditory center disorder or psychosis, drug effects, overdose or injection of narcotics, marijuana smoking and wrong consumption of hallucinogenic substances, drug allergy, etc. The physiological mechanism of hallucinations is not fully understood. Modern clinical research suggests that hallucinations are the result of misprocessing of signals in the auditory centers of the brain. We are not dealing with a silent world. Normal human hearing transmits internal and external sound signals correctly to the auditory center, while phantom listeners distort or exaggerate the sound signals due to a disorder in the auditory center. The brain incorrectly extracts sound information from memory and amplifies it also leading to hallucinations.
There are people in the world who are suffering from a category of hallucinations that do not fall within our common range, non-verbal, musical hallucinations that manifest as music and song. It is a strange condition where the sufferer is as if they have a music box implanted in their brain that will play at all times, never ending, which takes them into an endless nightmare. It keeps playing while you are awake, you don’t know what tune will come next, you may listen to the same one over and over again from morning to night, or you may hear music that doesn’t fit your state of mind at all.
In a professional journal of psychopathology (International journal of geriatric psychiatry), Victor Aziz and colleague Nick Warner published one of the largest studies of this disorder to date. They followed nearly 20,000 elderly people for 15 years and recorded a total of 30 cases. The average age of these patients was 78, and 87 percent were women, which seems to indicate that women are more likely to suffer from musical hallucinations. Of these, 13% suffered from bilateral deafness and 20% from unilateral deafness, and for the remaining 2/3 of the patients, musical hallucinations were their only mental disturbance. They conducted a detailed analysis of the type of music heard by the elderly patients and found that two-thirds of the patients heard carols from time to time, leading Victor Aziz to believe that the music heard by the patients may have originated from early life memories, as this is the type of music that the elderly, whose average age is nearly 80, heard most as teenagers.
Music is a complex sound, not a language, but it carries some meaning. So when confronted with such hallucinations, doctors are often at a loss. Some people believe that the signs that precede the onset of schizophrenia are: (1) involuntary thinking; (2) involuntary reenactment of past events; (3) daydreaming; (4) impaired comprehension; (5) loss of immediate memory; (6) a sense of being watched; (7) being paranoid; (8) short-lived musical hallucinations; and (9) urgent emotional confusion. However, all of these symptoms are not unique to schizophrenia and can only be used as precursors to a relapse of schizophrenia. In contrast, patients with prolonged musical hallucinations, some with delusions, most without delusions, and other symptoms not prominent, are again often accompanied by better self-awareness and a desire to seek treatment. Most patients are considered schizophrenic, but are not well treated with antipsychotic medications. Many patients reconsider the diagnosis and change their treatment plan only after multiple treatments have failed, thus causing immeasurable suffering and financial burden to the patient.
The first case of musical hallucinations that I came across in my clinic was in 1995. The patient was a kindergarten teacher. When she was hospitalized for an upper respiratory tract infection, she heard some vague contents of the doctor’s explanation of her condition to her husband outside the door and suspected that she was seriously ill, that everyone around her was deceiving her, and that her husband and others were united to harm her, and that explanations and persuasion were ineffective. A few days later the patient was admitted to a psychiatric hospital and diagnosed with schizophrenia. After treatment with Fenazen combined with Chinese herbal medicine, his delusions disappeared, but he still had hallucinations, manifested by endless and endless music with songs he had heard in the past, both sad and cheerful, which did not change according to his will, and the doctor thus switched to clozapine treatment. I took over and increased the dosage to 350 mg/day, but the situation remained unchanged, and the patient instead began to experience depression due to the longer hospitalization. I added sulpiride to clozapine to improve mood and gradually increased the dose to 600 mg/day. The patient’s hallucinations and mood improved significantly, but after continuing to increase the dose to 800 mg/day, the symptoms worsened again. The patient’s diagnosis was therefore brought to the medical record for discussion and reconsideration. After the discussion, the patient’s diagnosis was changed to “reactive psychosis, depressive state” and was treated with amitriptyline, considering that the delusions occurred under specific physiological and psychological circumstances, the hallucinations were non-verbal, the delusions disappeared rapidly, the patient was self-aware of the hallucinations, and the patient was obviously depressed. After amitriptyline systemic treatment, the patient’s hallucinations disappeared and his mood was normal. After more than ten years of follow-up, the patient relapsed within one year of stopping the medication, and was finally diagnosed with “recurrent depressive disorder” and was maintained on amitriptyline therapy. Since then, I have been concerned about musical hallucinations, asking about the presence and content of hallucinations and whether they are musical hallucinations during the psychiatric examination, especially when the patient has hallucinations as the main symptom or the main reason for the visit. Over the past ten years, I have come across many cases of musical hallucinations with similar conditions and various diagnoses, but all of them were accompanied by depressed mood for different reasons and to different degrees, and seven cases were treated with my systematic antidepressant therapy and all of them were improved. Through the analysis of Chinese and Western medical theories, it is concluded that musical hallucinations are closely related to depressive mood and have some diagnostic significance for depressive disorders.
Third, spleen deficiency, singing and depression
In Suwen Yin Yang Ying Xiang Da Lun, it is pointed out that the heart in the will is happiness, the liver in the will is anger, the spleen in the will is thought, the lung in the will is worry, and the kidney in the will is fear. If the five viscera are injured, the will will not be stretched and the external appearance of the spirit will change. If there is no soul in the liver, the spirit will be dull; if there is no spirit in the heart, the spirit will forget the front and back and act carelessly; if there is no intention in the spleen, the spirit will be doubtful; if there is no spirit in the lung, the spirit will be afraid of things, hesitant and uncertain; if there is no will in the kidney, the spirit will be sad and laughing, and the spirit will act carelessly. The relationship between the Five Elements and the Five Organs, the Five Wills, the Five Sounds, the Five Modes and the Five Tones is as follows.
The Five Elements
Five Tibetan
Five Wills
Five Sounds
Five states
Five Sounds
Wood
Liver
Anger
Hoo
Irony
Horn
fire
heart
joy
Laughing (words)
Calling
Sign
Earth
Spleen
Thinking
Song
Song
Gong
Gold
Lung
Sorrow
Crying
Chanting
Shang
Water
Kidney
Fear
moan
chanting
Feather
The spleen is the origin of the posterior, the source of Qi and blood biochemistry. The five viscera and six bowels depend on the nourishment of Qi and blood produced by the spleen in order to perform their respective physiological functions. Ming? Sun Yikui’s “Chishui Xuanzhu – Yu Men” says: “There are people with deficiency, once things are not as expected, dizziness of the head and eyes, shortage of spirit, impotence and shortness of breath, there is a deficiency-like evidence”, referring to the deficiency-based disease of depression. The deficiency pathology can be caused by deficiency, such as deficiency of Qi and blood, resulting in Qi stagnation, loss of nourishment of the heart and mind, and inability to stretch; deficiency of blood leads to deficiency of heart and blood, loss of nourishment of the heart and mind, loss of moistening of the liver and lack of drainage, resulting in internal stagnation; deficiency of Yang Qi is not able to make the warmth and agitation, resulting in Qi stagnation, and lack of extension of the mind. The deficiency can also be caused by depression. The stagnation of qi leads to the deficiency of the spleen and stomach, so that the clear qi cannot rise and the turbid qi cannot descend, making it difficult for the qi to be transformed and the water and grain essence cannot be distributed. The deficiency mechanism of depression is mainly deficiency, but the clinical picture is more mixed with deficiency and reality. Whether the deficiency leads to depression or the depression leads to deficiency, what we see is the manifestation of both deficiency and depression.
It is stated in “Ling Shu – Evil Guest” that “Heaven has five sounds, man has five hides: Heaven has six rhythms, man has six internal organs…This is the correspondence between man and heaven.” From the sound emitted by the human body, we can read the strength and weakness of the internal functions of the human body, and from this we can understand the extent to which the individual is in harmony with the external five elements of qi. There is a corresponding relationship between the reaction of emotion and the strength of the internal organs, and there is also a corresponding rule in the diagnosis of smell. According to the five sounds, music and singing should belong to the spleen. According to the five sounds, the wood sound is high and smooth, the fire sound is intense, the earth sound is deep and thick, the gold sound is harmonious and moist, and the water sound is round and urgent, all of which are signs of the inner organs being strong and strong, and are sent to the outside. On the contrary, if the Qi of a certain organ is weak, the sound of other organs can be seen due to the relationship between the opposite and the opposite. The music phantom hearing seen in the clinic is not loud, mostly seemingly, and even if it is loud, it does not reach the volume of a normal person, which does not have a direct impact on the patient, but only affects the patient’s learning and thinking, making the patient helpless. And the sound or high, or sweet, more languid and long, endless, but not see the caustic, thick sound. This kind of phantom hearing should be a false image. According to the internal organs, the heart and spleen deficiency should be the main.
In recent years, there have been more studies on the identification and typing of depressive disorders. Wang Yanheng divided depressive disorders into 8 types: liver depression and qi stagnation, liver depression and phlegm, qi stagnation and blood stasis, heart and liver incandescence, liver and kidney yin deficiency, heart and spleen deficiency, spleen and kidney deficiency, and yin deficiency and yang hyperactivity. Tang Qisheng proposed the TCM typing scheme for depression as 6 types: kidney deficiency and liver depression, heart and gallbladder qi deficiency, heart and spleen deficiency, heart and kidney disconnection, liver and gallbladder damp-heat, and liver depression and spleen deficiency, of which the kidney deficiency and liver depression, liver depression and spleen deficiency, and liver and gallbladder damp-heat types accounted for 60%. Similar classifications were found in other types of identification. Deficiency symptoms accounted for a higher proportion of depressive disorders, and the types that commonly contained spleen deficiency included liver-depression and spleen deficiency, heart-spleen deficiency, and spleen-kidney deficiency. In schizophrenia, on the other hand, for the shorter duration and acute phase of the disease, actual evidence is more common, and deficiency and stasis evidence are gradually more common in those with prolonged illness. Wang Yanheng divided them into 8 types: phlegm-fire internal knot, liver-fire internal knot, liver-depression-phlegm knot, liver-depression-spleen deficiency, liver-kidney two deficiencies, spleen-kidney two deficiencies, heart-spleen two deficiencies, and qi deficiency-blood stasis. Lai Qunqing divided chronic schizophrenia patients who were hospitalized for a long time into 7 types: qi stagnation and blood stasis, liver depression and spleen deficiency, heart and spleen deficiency, yin deficiency and fire, yang deficiency and deficiency, phlegm and fire internal disturbance, and phlegm and dampness internal obstruction, among which the qi stagnation and blood stasis, liver depression and spleen deficiency, and heart and spleen deficiency types were more common.
In terms of typology, both schizophrenia and depressive disorders have symptoms of spleen deficiency in their typology, with heart and spleen deficiency seen in multiple typologies of both disorders. However, spleen deficiency has a different status in different disorders. Spleen deficiency accounts for a higher proportion of the classification of depression, especially in Qisheng Tang’s typology, where two of the six types have spleen deficiency. Schizophrenia, on the other hand, has a higher proportion of deficiency types in long-term hospitalized patients. In other words, the same spleen deficiency is more common in depressive disorders, while schizophrenia is more common in later stages. When musical hallucinations first appear, they tend to have a short duration of illness, not as the deficiency evidence of schizophrenia in the later stages, but more closely resembling depressive disorders. For patients with short duration of musical hallucinations, in addition to considering the patient’s congenital spleen deficiency physique, we should also consider the role of the psychiatric symptoms represented by spleen deficiency in suggesting the diagnosis.
IV. Differential diagnosis
The pathogenesis, treatment, and prognosis of psychiatric disorders vary greatly, but the difficulty of symptomatological diagnosis often results in the eventual difficulty in confirming the diagnosis, leading to delays in clinical treatment. For patients with musical hallucinations as the main symptom, how to determine whether they have depressive symptoms and the status of depressive symptoms in the diagnosis of the disease is a problem that requires clinicians’ attention. The differentiation is mainly based on the following aspects.
1. Hallucinations and episodes: Patients should be asked whether they can control and influence the content and form of musical hallucinations, their appearance or not, and the timing of their appearance. Phantom hearing is not under human control. Appearances, which can be controlled and influenced to some extent, are to be considered as having compulsion.
2, true and false: many patients with musical hallucinations are unable to distinguish the source of the sound, they often can not distinguish whether it is heard by the ears or felt by the brain, but it does manifest as sound. Whereas true hallucinations tend to be more psychotic, pseudo ones are better. For treatment, true hallucinations plus some antipsychotic drugs may be more effective.
3, voice size: small voice, mostly false, more inclined to depression. The louder the voice, the more it belongs to the virtual reality, the more the presence of evil reality is considered, and the possibility of schizophrenia should be considered in the context of other manifestations.
4. Tone: Because of professional limitations and different levels of clarity in patient descriptions, it may be difficult for ordinary people to distinguish the differences in tone and pitch. The pitch of the tone and the properties of the five tones may not have any special diagnostic significance for Western medicine, but can have some significance for the properties of the internal organs and the identification of deficiency and reality.
5, the content of the song: the content of the song should be considered in combination with many factors, and should be combined with psychometric tests and interviews to see the patient’s reaction to the content of the song. Most patients do not have any choice about the content of the songs, but only songs they are familiar with or songs they have heard before.
6. Patients’ reactions to songs: Most patients are averse to songs, mainly because they think that songs affect concentration and the efficiency of study and work. Many patients do not have a positive attitude toward the treatment of singing, probably due to the therapeutic effect of music and psychological substitution, which somewhat alleviates depression and anxiety. Patients with emotionally indifferent schizophrenia who are truly indifferent to song are considered in conjunction with other symptoms. The reaction to the song has some significance for the identification of deficiency and reality. The stronger the reaction, the more it indicates the presence of real evidence, and the more indifferent it is the more it reflects the degree of deficiency.
7, self-knowledge: schizophrenic patients in the disease phase generally lack self-knowledge, and do not consider the appearance of singing as a pathology, but may have some of their own interpretation. The hallucinations of manic patients are similar to those of schizophrenic patients and often have a special interpretation of them. Such musical hallucinations are not fundamentally different from other hallucinations, but the spleen-earth locus is still relevant. A certain degree of self-knowledge exists in patients with depression, but it may not be complete. The more severe the patient’s depressive symptoms, the weaker his or her self-knowledge will be, and as the symptoms remit, self-knowledge will gradually be restored.
8. Depressed mood: Most music hallucinogists are able to elicit depressed mood, and even in schizophrenic patients, depressed mood may exist. However, not all music hallucinators have depression that they are able to experience; patients are often not very depressed, either because the depression itself is mild or because of the therapeutic and distracting effects of music, and thus some scholars believe that music hallucinations are simply a compulsive symptom. However, the treatment of clinical compulsions is generally more difficult and requires antidepressant doses that are often very large, whereas the antidepressant anti-dose for people with clinical music hallucinations is not very large.
V. Treatment
There is no specific treatment for music hallucinogens. On the basis of the diagnosis, if the musical hallucinations are psychotic, only antipsychotic medication is required. For the vast majority of people with musical hallucinations, antidepressant treatment is essential. If depression is clearly defined, only systemic antidepressant therapy is required. The dose of medication for patients with this type of depressive disorder is often not large, requiring only the recommended dose in the antidepressant medication instructions, and not an additional dose like most other patients with depressive disorders.
For patients who cannot be clearly diagnosed, such as true musical hallucinations with some delusions or invocation of ideas, antidepressant treatment based on experience is feasible. If there is concern during this process, antipsychotic medications can be combined in small amounts, both to target the possibility of psychotic symptoms and to relieve anxiety.
TCM treatment based on strengthening the spleen is effective, especially for mild to moderate depression, and can be very effective when treated properly, or can lead to deterioration when treated improperly or vice versa. Another case is provided below for illustration.
Patient Du, a 57-year-old female, practiced Falun Gong in 2004 due to type 2 diabetes and hearing loss, and gradually developed hallucinations, which manifested as hearing a male voice telling her to practice Falun Gong or else what to do. As the government declared Falun Gong an illegal organization, she stopped practicing. However, the voices became more and more serious, and conversations with them made it impossible for him to live a normal life. He was diagnosed with “schizophrenia” by a tertiary hospital and was treated with Risperidone 3mg/day to improve. At the beginning of 2005, he was first diagnosed with hallucinations of songs and depression, and was recommended to add paroxetine 20mg/day on top of the treatment, but his family was doubtful and returned to the original hospital for treatment. After outpatient and inpatient treatment, he was gradually increased to risperidone 6mg/day + olanzapine 15mg/day, which was ineffective. he was re-visited in early 2006, and there was no change in his symptoms compared to 1 year ago, only that his depressive mood had increased and the dose of medication had been increased. After adding antidepressant citalopram 20mg/day for 1 month, depressed mood and music hallucinations were reduced, combined with antidepressant and tranquilizer soup treatment for 3 months, mood was basically normal and song hallucinations disappeared. In the spring of 2007, the hallucinations of singing started to appear again, but they did not affect the patient. By summer frequent back sweating and sweat soaked clothes. Stopped citalopram for 1 month, no change in sweating symptoms. Check: normal mood, true verbal hallucinations, musical hallucinations, no thought content or form disorder, partial self-knowledge, normal intentional behavior; musical hallucinations are songs, faint, verbal hallucinations are not loud, false irritation when hallucinations appear; blue face, heavy around the eyes; sweating, no dry heat; weak limbs, normal diet, slightly dry stool; light red tongue with thin yellow coating, slightly smooth pulse, sunken and weak. The main treatment is to tonify the middle Jiao and benefit Qi, supplemented by nourishing Yin and clearing heat, tranquilizing the mind and stopping sweating, with Ginseng and Atractylodes macrocephala as the main treatment. The formula uses: Radix Codonopsis pilosulae 15g, Rhizoma Atractylodis Macrocephalae 15g, Poria 20g, Glycyrrhiza glabra 10g, Radix Astragali 25g, Radix Scutellariae 10g, Fructus Wheat 30g, Rhizoma Bone 30g, Radix Oyster 30g, Radix Lily 30g, Radix Rehmanniae 20g, Radix Salviae Miltiorrhizae 30g, Radix Paeoniae Alba 30g, Cornus Officinalis 15g. After 3 months of treatment with the addition and subtraction of symptoms, musical hallucinations disappeared, speech hallucinations remained, sweating symptoms disappeared, emotional stability, no The symptoms of sweating disappeared and the mood was stable without depression. The treatment was gradually reduced to one dose a few days based on this formula. The patient’s condition is stable, but the verbal hallucinations have not disappeared, but he is not moved and is able to perform household chores.
Discussion: The patient’s hallucinations were initially verbal hallucinations, diagnosed as schizophrenia, due to prolonged treatment, depressed mood, loss of liver qi, liver depression and spleen deficiency, and musical hallucinations with depressive symptoms. The patient was effectively treated with antidepressants and the musical hallucinations disappeared with Chinese and Western medications. The spleen in the sound for song, spleen disease and hallucinations for song, spleen deficiency, the sound is faint, verbal hallucinations sound is also smaller in the same way. In the early stage of liver depression and spleen deficiency, antidepressants and traditional Chinese medicine can de-stress the liver and regulate the qi, so that the qi can be regulated, then the spleen’s transportation improves and the qi and blood transportation tends to be normal, but the spleen is still insufficient. The reason for the improper use of drugs, not first real spleen, but every prescription must use calamus, long used to deplete the heart qi. Sweat for the heart, heart Qi deficiency is spontaneous sweating; eye chakra is earth, spleen qi deficiency is multiplied by the liver, and now wood color; Qi deficiency is spontaneous sweating, false irritability, weakness; long sweat injury yin, false fire disturbance, imminent sweating, fluid injury stool slightly dry, tongue and pulse match. Because of the drug injury, the spleen qi deficiency is more serious than the first time, so the musical hallucinations appear again. The treatment again, supplemented only with anti-psychotic drugs to strengthen the spleen and benefit the qi, was effective, which again verified the pathogenesis of spleen deficiency in musical hallucinations.