From Hong Kong J Psychiatry 2000;10(3):12-14.

CULTURE-BOUND PSYCHIATRIC
DISORDERS ASSOCIATED WITH
QIGONG PRACTICE IN CHINA

By Dr. HH Shan
(MD, Director, Department of Social and Cross Culture Psychiatry, Shanghai XuHui Mental Health Center, Shanghai, China.)

ABSTRACT

Qigong practice is a traditional form of psychotherapy in eastern countries that is an exercise of both body and mind. Qigong exercise will induce some mental disorders if it is incorrectly performed. The mental disorders induced by Qigong have been regarded as a diagnostic classification in the Chinese Classification of Mental Disorders since 1989.
This syndrome is associated with Qigong culture so may be termed a 'culture-bound' syndrome. The relationship between Qigong and psychiatry has become a very important topic in Chinese psychiatry.
 

INTRODUCTION

Chinese Qigong is an important cultural heritage of China and a part of traditional Chinese medicine. Chinese Qigong has been accepted as one of the many common psycho-physiological gymnastic exercises in China for 2000 years. Chinese Qigong exercise is similar to western meditation, Indian yoga, and Japanese Zen, which all function as a form of alternative psychotherapy. However, Chinese Qigong is based on the theories of traditional Chinese medicine and has influenced the training and practice of martial arts. Bio-psychophysiological changes occur in the human body that can influence mind and personality during Qigong practice.
Though the concepts of Qigong have not been fully defined, Qigong exercise has been accepted by many people around the world. Chinese Qigong practice can lead to abnormal phenomena, or even mental disorders, especially if practised inappropriately. During the years 1950 to 1965, there were reports that the practice of Chinese Qigong could lead to a deviation reaction. However, these events have not been reported in the psychology and psychiatry journals. For political reasons, Qigong practice was banned in China between 1966 and 1978. However, Chinese Qigong practice became popular again as China became more open. It is now estimated that more than 40 million people practice Qigong in China. Of the roughly 400 Qigong methods, 100 are currently very popular and are classified into hard or soft, inside or outside, with motion or motionless, etc. In recent years, increasing numbers of culture-bound psychiatric disorders associated with Chinese Qigong practice have been reported in China. Such mental disorders associated with Chinese Qigong practice could be regarded as a kind of culture-bound syndrome and this diagnosis has been accepted by the Chinese Classification of Mental Disorders (CCMD-2) and a Chinese textbook of psychiatry.
The syndrome has also been accepted by the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.(5) This term is defined as an acute, time-limited episode characterised by dissociate, paranoid, and other psychotic or nonpsychotic symptoms that occur after participation in the Chinese folk health-enhancing practice of Qigong (exercise of vital energy).

EPIDEMIOLOGY

Mental disturbance following meditation has been described in western culture (6) as well as in the Chinese traditional medicine literature. Such abnormal physical and psychological disorders are known as Qigong deviation syndrome. The first report occurred in China but has since been reported among Chinese living in other Asian countries and even in the USA. Since 1985, mental disorders associated with Qigong deviation syndrome have increasingly been reported in psychiatric journals and discussed in clinical practice.
Such abnormal psychological phenomena have aroused interest among medical circles and Qigong masters.

METHODOLOGY AND RESULTS

Details of an epidemiological study of 207 Qigong deviants performed at the Shanghai Institute of Qigong Research have been reported elsewhere.

The inclusion criteria for 'Qigong deviation syndrome' were:

• Normal behaviour before starting Qigong practice
• Psychophysiological reactions appearing during or after Qigong practice
• Manifestations of Qigong deviation syndrome not concurring with the diagnosis of schizophrenia and neurosis.

The results found that 62% of patients had psychological disturbances of varying degrees.
Of the 129 patients suffering from culture-bound syndromes associated with Qigong practice, there were 106 males and 23 females. Their ages ranged from 16 to 74 years with a mean age of 34.6 years. Among them, 100 patients practised Qigong by themselves, and only 23 under the tutorship of a Qigong master, while six practised in groups. According to the folk beliefs, the patients could be classified as having 'adverse flow in body' (62 patients), 'uncontrollable behaviour' (10), 'zou huo' or over-meditation (28), and 'spirit possession' (29).
Among the different psychiatric symptomatologies,
32% (41 patients) had sensory problems, 24% (31) had memory problems, 26% (34) had attention difficulties, 90% (116) had mood symptoms, 18% (23) had thought disorders, 37% (48) had behavioural problems and 3% (4) had disordered consciousness.

The authors conducted various psychiatric assessments for 'possessed' patients and found a mean Brief Psychiatric Rating Scale (BPRS) score of 44.8 ± 9.42, signifying quite serious psychopathology. They also evaluated 50 patients with mood symptoms and found anxiety and depression levels (mean Hamilton Depression Scale score of 16.8 ± 6.9 and Hamilton Anxiety Scale score of 16.0 ± 8.3, respectively) that were statistically higher than those of healthy controls.
The paper concluded that if Qigong is used inappropriately, it can produce abnormal psychosomatic responses.

DISCUSSION OF QIGONG-INDUCED PSYCHIATRIC DISORDERS BELIEFS IN CAUSATION

According to conventional beliefs, Qigong-induced psychiatric disorders could easily occur under the following conditions:

• The Qigong exerciser attempts to achieve an upper or top level coordination between mind and body at the beginning of the exercise, when Qigong practice should proceed step-by-step.
• Vulnerable individuals over-perform the practice. They are likely to have had neurotic disorders or personalities before they started practising Qigong. o Bad management of Qigong practice - the exerciser does too much Qigong, perhaps every day, or cannot stop practising.
• Some exercisers blindly self-teach themselves without proper guidance by a Qigong master. Some exercisers fail in the correct application of the three key elements of Qigong: management of body posture, management of breathing and exercise management. However, according to traditional Chinese medicine theories, the causation of psychiatric disorders could be due to one of the following reasons:
• Adverse qi (energy) flow in the body (neiqibuzhi !!)
• Out-of-control movement (waidongbuyi !!)
• Over-meditation (zouhuo __ )
• Being possessed (rumo __ ).

MANIFESTATIONS OF PSYCHIATRIC DISORDERS

It is quite interesting that most patients have relatively acute attacks of short duration. After the attacks, they feel relatively exhausted and many have partial or complete amnesia about their behaviour. The most common syndrome is an acute psychotic reaction, quite a significant proportion of which are similar to that of schizophreniform disorder.
These psychotic syndromes usually occur a couple of days after Qigong practice. Other presentations could mimic affective disorders, dissociative (hysteria), and other neurotic disorders. For those diagnosed with schizophreniform disorders, the clinical symptoms include delusions, hallucinations, and disorganised speech. Quite often, there is accompanying over-talkativeness and elation of mood. There can also be abnormal behaviour, especially that of 'posturing' using the various exercise postures of the Qigong practice. The first rank symptoms of schizophrenia described by Schneider such as thought control or alienation may be apparent, but are not always present.(11)
A number of patients could be described as suffering from an affective disorder, with either depressive or manic episodes. For those diagnosed as having various forms of neurotic disorders, the clinical manifestations can be divided into physical and psychological forms. Nearly all patients have a special complaint of something like "the Qi moving within the body, and dashing or rushing into the head". Often, such `qi' becomes stagnated somewhere, leading to headache, dizziness, or strange perceptions in the lower abdomen (called the `Dan-Tian point'). Psychological symptoms include hypochondriasis, obsessive thoughts or images, phobia, suicidal ideas, and feelings of sadness, anxiety, and worries about being out of control. For those who manifest with the dissociative state (previously labelled the 'hysteric syndrome'), there are features of disturbed consciousness, disorientation of time, place, and person, and visual and auditory hallucinations. Such features usually occur after Qigong practice for 2 weeks or a month.

CASE HISTORY

Mr A is a 44-year-old married male painter. He taught himself He Xiang Zhuang (a popular Qigong method since 1984 for the treatment of disease of the cervical vertebra). He had no previous psychiatric history or any family history of psychosis. Several days after Qigong practice, he suddenly became agitated and dysthymic. He claimed that he knew something special about the world including "the sea is associated with water". He talked to the sea and had American ideas in his head. He was subsequently diagnosed as having a schizophreniform disorder and was admitted to a local psychiatric hospital. One month later, he had a relapse while practising the 'long men five flow', which is a Qigong method. On the third morning after the practice, he suddenly cried aloud and danced around. He thought that his deceased mother had come back to life but that he would become a ghost. He said that he could see the images of Buddha and other gods and he smelt a special smell. He intermittently maintained a special Qigong posture. He was thus readmitted into the psychiatric hospital. The Rivermead Postconcussion Symptoms Questionaire showed extroversion while the Minnesota Multiphasic Personality Inventory showed schizophrenic character. He was given chlorpromazine 100 mg intramuscularly twice daily. A week later, he was completely recovered and had resumed work.

DIAGNOSIS OF A CULTURE-BOUND SYNDROME

Assumption of the diagnosis of an abnormal Qigong reaction as a culture-bound syndrome is controversial. There is a specific diagnostic category in the CCMD-2.
The definition can be translated as follows: "Qigong deviation reaction syndrome/mental disorder associated with Qigong is characterised by incorrect methods, exercise misuse or over-meditation, too much Qigong or maintaining the Qigong state for too long, with the appearance of some somatic or psychological disturbances during the early phase of Qigong practice. Thinking disorders, disorders of mood, and disorders of behaviour may appear."
The diagnostic criteria include the following:

• The onset of the mental disorder occurs after Qigong practice.
• The syndrome is associated with some kind of Qigong method in a book or identified by a Qigong instructor, with abnormal language and uncontrolled behaviour, which does not cease after Qigong practice has stopped.
• The mental disorder cannot be classified or excludes the following conditions: - the condition is a result of self-treatment or treatment by others for a physical or psychological aim - the condition is aimed at cheating others - the condition can be self-induced or stopped at will.

The mental disorder cannot be diagnosed according to the CCMD-2.

PREVENTION

The problems of mental health associated with Qigong practice have aroused much interest from psychiatrists and psychologists. Hopefully, such culture-bound psychiatric disorders associated with Qigong practice can be prevented if adequate psychological education can be provided to all Qigong practitioners before and after starting such exercises. Current research suggests that Chinese Qigong is a traditional healthy exercise method. People practising Qigong can improve health, increase strength, reduce stress, develop creativity, and even treat some diseases. There is a famous saying - "Qigong practice can treat disease if you have some disease, and prevent or protect you if you do not have a disease." But not every kind of Qigong is suitable for all people. People choose a specific Qigong method according to their condition, and there needs to be better clarification in this area of practice according to scientific principles. Indeed, such culture- bound psychiatric disorders associated with Chinese Qigong practice is becoming more common in China and other Asian countries, such that mental health practitioners should be aware of their presence when treating patients.

REFERENCES

(The notes 1-4, 7-10 are only written in Chinese fonts)
5. American Psychiatric Association. Glossary of culture-bound-syndrome, DSM-IV. 4th ed. 1995:847.
6. West M. Meditation. Br J Psychiatry 1979;5:457-467.
11. Schneider K. Clinical psychopathology (Special ed.). New York: Grune & Stralton; 1993.

Dr HH Shan, MD, Director, Department of Social and Cross Culture Psychiatry, Shanghai XuHui Mental Health Center, Shanghai, China.

Address for correspondence:
Dr Huaihai Shan
Director Department of Social and Cross Culture Psychiatry Shanghai XuHui Mental Health Center No.54,
Xiqin Road Shanghai,
200233 China

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