I cannot forget a patient from 2008 who I almost didn’t help. What would you think, if a patient came to you explaining that he has terrible, uncontrollable diarrhea, but only when he crosses the threshold of his front door to go outside? In other words, he has no problem at all, when he just stays at home. I can tell you what I thought: This is a mental health case, and I should refer this person out to a therapist or even a psychiatrist. However, I was wrong. 

Anger, sadness, worry and fear – I factor basic emotions into my diagnoses but not the inability to go outside. Content like that is the domain of psychotherapists, and they will ask follow up questions about those sorts of things. Should a thought like, “I am now leaving my house,” trigger a physical reaction in someone, conventional wisdom is that they need a therapist.  

I have to say, though, and I think many people with a history of digestive problems will agree, that I really dislike the word “psychosomatic.” It has been used to dismiss the physical experiences of millions of people with unexplainable digestive disorders. In addition – almost like salt to the wound – it is a limited diagnosis because our understanding of the mind, as well as the mind-body axis, is limited. The phrase “placebo effects” has been used in a similar, dark way, so I believe these two terms – psychosomatic and placebo effects – are worth comparing.  

At a party, I once shared this inside-outside case with a couple of research scientists. Really, I’m embarrassed that I privileged them with the story, because they nonchalantly called the result of my treatment a “placebo effect.” They blew it off. Now, please understand, the fact of placebo effects does not bother me at all. They are a natural part of Medicine, and I know a great deal about them, actually a great deal more than those scientists do. Their use of “placebo effects,” similar to how many professionals use “psychosomatic,” was as a dismissive catch-all – sort of like a kitchen junk drawer. If a treatment result cannot be easily explained, well then it must be a placebo effect. If a condition does not show up on a lab result or imaging, then let’s dismiss it as psychosomatic and be done with it (at least on our end, thinks the doctor) and put it into the junk drawer. 

Both placebo effects and psychosomatic illnesses are descriptors of real phenomena. I won’t be dismissive of them as concepts. Their ubiquitous overuse is another story. The imprecision displayed by those scientists at the party is just lazy and appalling. One should not go around dismissing people’s experiences just because it does not fit easily into one’s cozy little universe. You see, this patient – let’s call him “Alex” – had already taken his diarrhea problem to a primary care, a psychiatrist, and a psychotherapist. It had persisted for a year, while they tried to do something about it. 

If you know anything about placebo effects, then you know it matters who gives you the placebo. When your doctor gives you a sugar pill, it is not the same as a stranger on the corner giving you a sugar pill, because it does not carry the same meaning. So, are we to assume that these esteemed professionals could not pull off a placebo effect for Alex, using prescription drugs, while someone on the fringes of medicine – a last resort practitioner like me – could? Nonsense. Alex’s cure cannot be explained as a placebo effect. Sure, he was polite to me, but he had no reason to respect me. Frankly, I was his last choice. This goes for all acupuncturists and TCM herbalists everywhere, who are often accused of making a living by dishing out placebos. At the time, I wasn’t even much older than Alex was – not exactly representing “doctor” material.

Alex said “When I leave my house, I can’t stop going to the bathroom… I can’t stop shitting my pants” – these were the words he used, and they were a self-condemnation. He was vulnerable and embarrassed. “And when you stay home?” I asked. “Well, then I’m okay, there’s no problem.” Alex went on to tell me of the ways this problem had ruined his life: “I’ve lost everything – my job, my car, my friends, and my girlfriend. I’m also broke.” He was completely matter-the-fact and flat affected as he said all of this. He took a deep breath – shifted a little. “I’ve tried everything, all I can do is stay at home.” 

The other medical professionals had tried various antidepressants, antidiarrheals, and some medications that Alex could not remember. However, the inside-outside problem did not budge. His therapist had became frustrated, and I can see why. Alex’s thoughts about his problem didn’t exactly scream “insight,” and he wasn’t even much of a talker.  

I asked some questions, looked at his tongue, took his pulse, and felt his abdomen. His hands and feet were freezing. I left him in the treatment room, went to my desk, leaned back, and sighed. Fine at home but unable to stop going as soon as he crossed the threshold of his door? I was already dismissing him in my mind. So strong are our cultural assumptions about mental and physical health that I could not see past them or even realize that I should look. It was as if “psychosomatic” had been written in big, red letters on a billboard outside of my window. I was forgetting my eduction. What about the good data that I had already collected? What about his frigid extremities, his wiry pulse, his purple tongue – and all the rest? 

I wanted to go and tell Alex that there was nothing I could do. Then I considered that he had nowhere else to turn. Out of obligation, a doing-what’s-right, and a whim – I decided to try. As I sat there, I saw a formulation already written up, pinned to my wall. It was Si ni san (“four reversals powder”), which I had been studying. An MD friend once commented that the moment he learns something new, patients with that problem (or solution) begin showing up. After decades of practice, I know that he’s right, and it happened that day. 

The “four reversals” refers to the hands and feet, which are cold in these patients. Symbolically, this is because what should be flowing outward – blood, heat, qi, prana, friendship, whatever – is reversing and only flowing inward. It is like venous valves, should there be no arteries. What had once circulated freely is now on a single, one way street. The analogy of being stuck inside and not flowing outside suddenly came to me. It was like a physical version of introversion. For the first time in that case, I put aside my skepticism and went all in on formulating an answer. 

Traditional herbal formulas have internal logic of one sort or another. Some can be purely scientific, but most of these do not work well. Si ni san is ancient, having been published 1,800 years ago. Formulas of that time come in fours, and they have strong internal organization. Within Si ni san each of the four herbs moves within the body in a different direction:

Si ni san (four reversals powder):

Chai hu (Bupleurum) — Moves out
Zhi shi (unripe Bitter Orange) — Moves down
Bai shao (Peony root) — Moves in
Zhi gan cao (honey fried Licorice)— Moves up and to the center

This isn’t as abstract as it seems. For examples, Chai hu moves out because it causes sweating, and Zhi shi moves down because it promotes bowel movements. What occurred to me is that Alex needed movement not containment (the very opposite of antidiarrheals). In a sense, he already had too much limitation. A treatment principle popped into my mind, which is called “stopping by going.” In recent visits to health subs on reddit, I’ve noticed that many people with diarrhea are utilizing this principle by taking laxatives to firm up and decrease the frequency of their stools. This is precisely the same treatment principle but without the great moniker. 

At the time, green-newbie that I was, I was very concerned about giving an herb like Zhi shi to Alex, which is typically used to treat constipation. Still, I prescribed Si ni san as you see it below, modifying the original formula by adding a couple of herbs and increasing the dose of herbs that move downward and outward:

Chai hu 12 g
Zhi shi 12 g
Bai shao 4.5 g
Zhi gan cao 3 g
Chuan xiong 6
Mu xiang 9

This formula increases movement within the body, especially out and down, because the last thing Alex needed was further blockage. I gave it to Alex and asked him to come back in a week. At the following appointment, Alex had completely changed. He said, “that stuff you gave me tastes terrible, but it really works.” He was energetic and upbeat, explaining that within a day of starting the formula his symptoms had improved. Within a few days, he no longer had diarrhea and was able to come and go from his house as he pleased. I prescribed another batch of herbs, and Jim agreed to come back, but he cancelled the next appointment. He told the receptionist that he no longer needed treatment. I called him up a month later, just to see how he was doing. He was doing great, and he thanked me. 

These days we have research to support the use of Si ni san for many conditions – clinical trials, basic research, -omics research, etc. A search on pubmed (just search up “sinisan”) returns 90 scientific papers. This is far more than what was available in 2008. However, none of those papers speak specifically to Alex’s case, and none ever will. Yes, there may be some research on depression, on IBS, on cold hands and feet – yet, none of this really calls to mind precisely the right specifics of that case. Furthermore, there can be no rationale, based on research, for modifying Si ni san the way that I did. What I prescribed was individualized. Should someone decide to prescribe herbs based entirely on research, I am certain that they will never be able to handle a case like Alex’s, not to mention many other digestive disorders.

What one sees as proof or perspective can turn into limitation, just like a turn of the hand. Nature is complex. It is fickle. Finding inroads requires flexibility within our own frames of mind. The choice of vantage changes what is possible. It changes the outcome, and it may facilitate getting the right medicine to the right patient at the right time. Do I always approach my cases in terms of analogy? No, of course not – that would be rigid. Here, though, it worked.

Meanwhile, there is a self-satisfying cult of perspective in the use of both “placebo effects” and “psychosomatic.” In this instance, they are pat, junk-drawer answers. They are conveniently used as glue – to hold together a patchwork worldview and prevent the mental expansion that comes from having one’s ideas challenged. Poor Alex, should he have lived not one but ten years within that perspective. Poor me, should I have dismissed him and sent him back to the dogs.‡