AUTISM
Autism is characterized by profound disturbance in the emergence of social relations, apparent as early as the first months of life and almost always by age three years (1). Disturbances in brain maturation appear to be a cause of this syndrome, which may be exacerbated by deficiencies in certain nutrients (e.g., vitamin B6, magnesium, glycine, glutamine), by allergies to foods, and other factors. The severity of symptoms can vary markedly between individuals and in response to treatment.
The relationship of serotonin to autism has been investigated extensively, but the implications remain unclear due to conflicting findings. Serotonin levels in autistic individuals tend to be elevated (2, 3, 8), as are the levels of the serotonin precursor tryptophan (11), with apparent increase in symptom severity correlated with the tryptophan levels. In fact, a hypothesis has been put forward (2) suggesting that there is a maturation defect in the monaminergic systems in autism. Alternatively, however, it may be that the defect in serotonin metabolism is a marker for tendency to experience autism but is not a cause of the disorder. Relatives of autistic children are found to have a variety of serotonin-metabolism disorders, but not the mental disorder (9). A serotonin lowering drug, fenfluramine, was tested (10) in a double-blind placebo-controlled trial, but no obvious therapeutic effect was noted. On the other hand, a test (12) of both the dopaminergic antagonist (amisulpride) and the dopaminergic agonist (bromocriptine) did show some effects that might indicate a role of the monoamines in autism symptoms. The evidence thus far points to a role of monoamines in the severity of autism symptoms but it appears that the biochemical imbalance is not the sole disorder leading to autism.
Autism has been correlated with other childhood disorders that are related to brain function, such as attention deficit disorder (ADD), mental retardation, epilepsy, and learning disabilities (4). While the specific mechanisms and manifestation of these disorders differ significantly, there is a relatively high incidence of one or more such disorders occurring simultaneously and a similar benefit is claimed to using certain nutritional approaches, such as administering nutritional supplements and avoiding allergens.
Chinese books on pediatrics do
not mention autism, and this subject does not appear in the modern Chinese
medical journal literature either. In
the book Clinical Experiences (5), a
condition is described as follows: disturbance in mental development, apathy,
tardiness of speaking...” which is described as a syndrome of “heart blood”
deficiency and the suggested treatment is an herbal formula given as a
decoction, consisting of 10 grams each ginseng, ophiopogon, and acorus, 6 grams
each of tang-kuei and polygala, 5 grams of frankincense, 3 grams of cnidium,
and 1.5 grams of cinnabar. This formula
nourishes the heart qi, yin, and blood, vitalizes the heart blood, removes
phlegm obstructing the orifices of the heart, and calms the agitation of the
heart spirit (shen). This prescription might be compared with the
formula recommended in the pediatrics volume of the Encyclopedia of Traditional Chinese Medicine (6) for treatment of
hyperkinetic syndrome in patients who display symptoms of “changeable
interests, divided attention, amnesia, dreaminess, stutter, or problems in
formation of phrases and sentences....”
The formula is as follows: 12 grams each of pseudostellaria and
astragalus, 9 grams each of hoelen, atractylodes, tang-kuei, polygala, acorus,
and schizandra, with 15 grams of wheat, 6 grams of licorice, and 10 pieces of
jujube. This is basically a combination
of Licorice and Jujube Combination (Gan
Mai Da Zao Tang), and Astragalus and Zizyphus Combination (Yang Xin Tang), two traditional formulas
used for mental disturbance. The new
formula tonifies the qi and blood, removes phlegm obstruction of the orifices,
and calms the spirit.
In an article (7) reviewing basic Chinese medical treatments for mental syndromes, the classical division of mental disorders into “dian” and “kuan” types is made. The dian type refers to taciturn and uncommunicative behavior, dementia, lack of sympathy, apathy, and soliloquy; it refers to the person who turns inward. This is closest to the autistic condition. The kuan type, by contrast, is very aggressive; it refers to the person who acts out, loudly and sometimes violently. The famous physician Zhou Danxi stated “Dian belongs to yin and kuan to yang...both conditions are caused by the entanglement of phlegm in the heart...” The ancient texts also attribute the dian and kuan states to congestion of the seven emotions which generate phlegm and mask and obstruct the orifice of the heart. A general formula for alleviating the phlegm obstruction is made by combining pinellia, magnolia bark, perilla fruit, hoelen, arisaema, curcuma, acorus, polygala, perilla leaf, sinapis, raphanus, bamboo juice, and styrax (liquid). Deficiency of qi and blood also gives rise to the dian condition; for symptoms and signs that include spiritlessness, suspiciousness, melancholy mood, refusal of food, soliloquy, and tendency to cry, the formula recommended contains codonopsis, atractylodes, astragalus, tang-kuei, licorice, polygala, fu-shen, saussurea, ginger, jujube, wheat, nardostachys, fu-shou, citrus, zizyphus, albizzia, polygonum stem, and dragon bone. In the book Clinic of Traditional Chinese Medicine (13), a formula for dian type condition (stagnancy of phlegm and qi), the indications include apathy, dementia, muttering to oneself, and the treatment is 12 grams of curcuma, 10 grams each of citrus, pinellia, hoelen, arisaema, chih-shih, polygala, acorus, and cyperus, and 6 grams of licorice.
In the review article (15) on the classification and treatment of mental disorders, early Chinese writings about various mental syndromes are mentioned. Among them is this commentary attributed to Li Peng in the Ming Dynasty book Entering the Door of Medicine:
The mental disorders is described in but one word: phlegm. These diseases are mostly caused by internal injury and only extremely rarely due to external pathogenic influences. The internal trauma, excessive wetness, inappropriate diet, food stagnation, could produce phlegm fire. Then uprising phlegm fire masks the heart orifices. When the person was frightened or fearful or worried or thinking too much, the fire will become more vigorous and then the spirit will not be able to reside in its house. Then the phlegm would suffocate the empty house.
The formulas described above clear out the accumulated phlegm and help prevent formation of additional pathological phlegm. It is important to recognize, however, that adverse dietary practices can overcome the impact of the herbs.
Discussing specifically the dian type of mental condition, it is said (13, 15) that it is mostly caused by traumatic injury to the seven emotions. The injured emotion will lead to heart fire, obstruction of liver qi, and failure of the ascending of the spleen qi. When qi becomes stagnated, the body fluid will accumulate and condense to form phlegm. The uprising of phlegm will interfere with and cloud the spirit. As an example of a specific treatment, the following herbs are suggested: 12 grams of hoelen, 9 grams each of pinellia, citrus, chih-shih, bamboo, cyperus, and polygala, 6 grams each of curcuma, acorus, saussurea, and licorice, plus 3 slices of fresh ginger.
To what extent might these theories and treatments for a yin-type mental disorder apply to the autistic child or adult? Many of the discourses on mental disorders by Chinese doctors refer to people who develop the mental syndrome after being relatively normal, but are then influenced by some events. While this may be the case in some autistic children, current Western investigations suggest that there is a physical and biochemical disorder present at birth. However, the severity of symptoms can be modulated in many children by diet, nutrition, and drugs, and therefore Chinese medical treatments for similar symptoms acquired in individuals through various experiences (which would affect the biochemistry rather than the physical structures of the brain) may be applicable.
Which particular combination of herbs, though, might work best for an autistic child? One can not know until something has been tried. The only report available to us on treatment of autism with Chinese herbs is an informal communication from a medical doctor in Belgium who had studied with this Institute. He claimed that he had obtained a notable favorable response in several autistic children using the prepared Bamboo and Ginseng Combination (Zhu Ru Wen Dan Tang). This formula contains bamboo, licorice, coptis, bupleurum, hoelen, ginger, pinellia, ginseng, cyperus, citrus, and chih-shih. As with the formulas mentioned above, it includes digestion-promoting, phlegm-resolving, and sedative herbs. Unlike some of the above, it contains none of the blood tonic herbs. The report of effectiveness was made several years ago, and the Institute does not have current contact with this physician.
More recently, a formula for treatment of ADD was developed by ITM, called Acorus Tablets (21), and several informal reports of effectiveness were obtained from practitioners who gave it to their patients. This formula contains acorus, polygala, fu-shen, alpinia, curcuma, rehmannia, dragon bone, dragon teeth, oyster shell, bamboo sap, tortoise shell, and succinum. Like the above formulas, it contains herbs for resolving phlegm, sedatives, and blood tonics, but it contains only one herb for promoting digestive functions (alpinia). This formula was based on the claimed effective use of similar combinations for the treatment of ADD in China. In the treatment of epilepsy in children, similar formulations are used, with an emphasis on resolving phlegm obstruction. Another combination (21) produced by ITM, Cyperus 18, was designed to treat mental depression that arose from the syndrome of heart fire, liver qi stagnation, and poor conductance of food essence by the spleen, with resultant phlegm obstruction. This formula contains cyperus, perilla leaf, bamboo, uncaria, saussurea, bupleurum, aurantium, fu-shen, pinellia, chih-shih, coptis, ginseng, ophiopogon, tang-kuei, cnidium, ginger, arisaema, and licorice. Informal reports have indicated that it is often successful. As an example, a patient at our own clinical facility (under treatment for multiple sclerosis) had used antidepressive drugs for eight years, but was able to discontinue the drugs after use of this formula for less than six months.
Given the limited experience thus far and the commentaries from ancient and modern writers about treatment of mental disorders, including childhood problems such as ADD, mental retardation, and epilepsy, it would appear that the most likely approach to prove helpful is to utilize the phlegm-resolving herb compounds. It is possible that the digestion-promoting and qi and blood tonic therapies used in China accomplish a function similar to the use of vitamin and amino acid therapies in the West. Since the latter have been tested and appear safe and somewhat effective, one may decide to utilize the Western nutritional approach and the Chinese method of removing “phlegm obstruction.”
The most frequently used herbs for treating phlegm obstruction that causes mental disturbance are polygala and acorus. Polygala has a long-standing reputation in China for improving mental conditions. According to British doctors (16) who visited China during the previous century, polygala “is supposed to have a special effect upon the will and mental powers, giving strength and character, improving the understanding, strengthening the memory, and increasing the physical powers.” Acorus is reported (17) to be effective in the treatment of epilepsy of the phlegm-dampness and phlegm-heat types, being of benefit in 80% and 55% of cases respectively. It is similarly reported that if acorus is added to a basic sedative formula, it is effective in treating melancholia and that “patients abandon the idea of suicide by taking about 7 doses of the decoction.” In a book (18) reviewing the current uses of commonly prescribed Chinese herbs, both acorus and polygala are mentioned as treatments for epilepsy and mental disorders, with acorus specifically mentioned as valuable in the treatment of children. In another book (19) reviewing the modern use of herbal formulas, it is mentioned that the combination of arisaema, polygala, and acorus are added to other formulas for the symptomatic treatment of “spiritual inertia.”
Of course, when a skilled practitioner is available to access the needs of the autistic child, it might be determined that qi and/or blood tonics, or other herbs are needed. These would especially be suggested if the child is growing slowly, is pale, or has a weak pulse. A suggested herbal combination based on the above considerations would be comprised of ginseng, hoelen, pinellia, citrus, ginger, jujube, licorice, acorus, polygala, tang-kuei, fu-shen, and bamboo. For convenience of obtaining herb supplies and administering herbs in pill form (if desired), this combination could be approximated by using Er Chen Wan (traditional formula made as a patent medicine) plus Acorus Tablets (child size tablets).
Some Chinese herbs have been shown to reduce serotonin levels or inhibit the action of serotonin (20). Serotonin is a mediator of pain signals, and analgesic herbs sometimes function via reducing the signal transmission. Diterpene alkaloids, such as aconitine (from aconite) and methysergide, block the effects of serotonin. Rauwolfia alkaloids, such as reserpine and rhynchophylline (from uncaria), deplete serotonin. Volatile oils from asarum and acorus also lower serotonin levels (the active constituent in acorus is asarone). Of these herbs, only acorus is frequently mentioned in the formulas above, though uncaria is often used in treating mental disorders (included in Cyperus 18), and is used in children’s remedies. A formula comprised of aconite, dry ginger, cinnamon bark, and licorice was utilized (14) in treating dian-type schizophrenia characterized by little change in facial expressions, dull eyes, decrease in self-initiated movements, inability to love, talking little and having sentences with little content or unfinished, and lack of interest in socializing. the recommended dosage of aconite was quite high. It is possible that the serotonin-inhibitors reduce the symptoms of the dian type mental disorders. To obtain a serotonin-inhibiting action, the dosage of the herbs may need to be higher than is often recommended for treating other disorders. The need to use high dosages is also the situation with nutritional supplements applied in Western studies of autism.
In a review of vitamin B6 and magnesium supplementation trials provided by the Autism Research Institute, the dosage of the vitamin administered covered a wide range, but was typically 30 mg/kg/day up to about one gram per day, and magnesium dosage was typically 10–15 mg/kg/day, up to about 500 mg. These levels far exceed what is available from dietary sources. Glycine, in the form of dimethylglycine, is recommended in dosages of 125–500 mg/day, starting with a low dose and increasing gradually to minimize the occurrence of hyperactivity in response to initial dosing.
Due to the lack of familiarity of most Westerners with Chinese herbs, leading to questions about their safety, efficacy, method of application, and duration of use, it can not be expected that Chinese herb formulas will be widely utilized in the treatment of autism, especially in young children. However, there is sufficient evidence that Chinese physicians have had experience and some success in treating mental disorders similar to autism (perhaps sometimes autism itself), so that it is a method that should be pursued with due caution along with the recommended dietary and nutritional approaches. There are several herbal formulas which have been used extensively in the West without significant adverse effect that can be used as the starting point for experimental treatments.
References
1. Cohen DJ, et al., Integrating biological and behavioral perspectives in the study and care of autistic individuals in the future, Journal of Psychiatry and Related Sciences 1993; 30(1): 15–32.
2. Rolf LH, et al., Serotonin and amino acid content in platelets of autistic children, ACTA Psychiatry Scandinavia 1993; 87(5): 312–316.
3. Cuccaro ML, et al., Whole blood serotonin and cognitive functioning in autistic individuals and their first-degree relatives, Journal of Neuropsychiatry and Clinical Neuroscience 1993; 5(1): 94–101.
4. Rimland R, ARI recommendations on treatments for autistic and other mentally and neurologically handicapped children, Autism Research Institute 1993; 49.
5. Shang Xianmin, et al., Practical Traditional Chinese Medicine and Pharmacology Clinical Experiences, 1990 New World Press, Beijing.
6. Xu Xiangcai, et al., English-Chinese Encyclopedia of Practical Traditional Chinese Medicine, 1990, Higher Education Press, Beijing.
7. Peng Zheling, Seven treatments for mental patients, Journal of the American College of Traditional Chinese Medicine, 1992; 4: 12–17.
8. Naffah-Mazzacoratti MG, et al., Serum serotonin levels of normal and autistic children, Brazilian Journal of Medical and Biological Research 1993; 26(3): 309–17.
9. Cook EH, et al., Platelet serotonin studies in hyperserotonemic relatives of children with autistic disorder, Life Sciences 1993; 52(25): 2005–2015.
10. Leventhal BL, et al., Clinical and neurochemical effects of fenfluramine in children with autism, Journal of Neuropsychiatry and Clinical Neuroscience 1993; 5(3): 307–315.
11. Hoshino Y, et al., Blood serotonin and free tryptophan concentration in autistic children, Neurophyschobiology 1984; 11: 22–27.
12. Dollfus S, et al., Amisulpride versus bromocriptine in infantile autism: a controlled crossover comparative study of two drugs with opposite effects on dopaminergic function, Journal of Autism and Developmental Disorders 1992; 22(1): 47–60.
13. Zhang EQ, et al., Clinic of Traditional Chinese Medicine, 1988; Publishing House of Shanghai College of Traditional Chinese Medicine, Shanghai.
14. He Shaoqi, Xiandai Zhongyi Neike Xue 1991; Zhongguo Yiyao Keji, Beijing.
15. Cheng Jianxu, Classification and treatment of mental disorders by traditional Chinese medicine, Journal of the American College of Traditional Chinese Medicine 1987; 3: 31–62.
16.
Smith FP and Stuart
GA, Chinese Medicinal Herbs;
reprinted 1973, Georgetown Press, San Francisco, CA.
17. Dong ZL and Yu SF, Modern Study and Application of Materia Medica, 1990, China Ocean Press, Beijing.
18. Ou Ming, editor, Chinese-English Manual of Commonly Used Herbs in Traditional Chinese Medicine, 1989 Joint Publishing Company, Guangdong.
19. Wang Qi and Dong ZL, Modern Clinic Necessities for Traditional Chinese Medicine, 1990, China Ocean Press, Beijing.
20. Dharmananda S, Analgesic components of herbs and their mechanisms of action, START Group 1993, Institute for Traditional Medicine, Portland, OR.
21. Dharmananda S, A Bag of Pearls, 1994 Institute for Traditional Medicine, Portland, OR.
August 1997