TCM Eight Principles, Pathogenesis, and Pattern Differentiation – Comprehensive Notes

Eight Principles and Pattern Differentiation (TCM) – Comprehensive Notes

• Core idea: Do not collapse complex disease patterns into a single line. Evaluate deficiency and excess, interior and exterior, cold and heat, and yin and yang separately for each point/location. This is the foundation of the eight principles.

  • Eight Principles framework: the relationships between two opposite aspects across four dichotomies yield the core diagnostic pattern:
  • Exterior vs Interior
  • Cold vs Heat
  • Deficiency vs Excess
  • Yin vs Yang
  • In practice, patterns are rarely pure; many cases involve mixed patterns where deficiency and excess coexist, or interior/exterior elements are layered differently. Always assess the combination, not just one facet.

• Key definitions (basic nomenclature used in lecture):

  • Deficiency: ext{Deficiency} = ext{insufficiency of upright qi}
  • Excess: ext{Excess} = ext{exuberance of pathogenic qi}
  • Pathogenesis can be described as two broad axes: too much vs too little, and the pathogen’s location or state (exterior/interior).
  • The idea of “100% deficiency” or “100% excess” is misleading; evaluate both ends separately for each syndrome location. The severity can vary; even mild conditions can present as 100% deficiency if there is no excess at that point, and vice versa.

• Pathogenic qi and the six external pathogens (pathogenesis mechanisms)

  • There are multiple types of pathogenic factors in TCM; core idea is that they enter or affect the body and interact with upright qi.
  • The six external pathogens concept, when explained, includes common factors like wind, cold, heat, dampness, dryness, and toxins, which can be environmental or internal transformations.
  • Important distinction: pathogenic components discussed are direct pathogens impacting the body; initial (exterior) pathogens can trigger changes that develop into other pathogenic factors (e.g., dampness leading to phlegm, turbidity, or toxins).
  • Direct pathogens: initial triggers that attack the body directly; exterior cold/heat can trigger transformations that become dampness, phlegm, turbidity, or toxins over time.
  • Byproducts and transformations: dampness can lead to phlegm, turbidity, and eventually toxins; toxins are described as necrotic factors with tissue-killing capacity.
  • Blood stasis is a final product of several pathogenic processes and/or deficiency and can itself be a pathogen or a product that aggravates the condition.
  • Sensible progression circle: pathogens and byproducts (including dampness, phlegm, turbidity, toxin) can transform into each other and into blood stasis; each may act as a pathogen depending on context.

• Upright qi and the nine energies (正气, nine types of upright energy)

  • Concept: upright qi acts as the body’s defensive and nourishing force against pathogens; it is organized across multiple levels.
  • The speaker traces nine kinds of upright energy, moving from surface to interior:
  • Exterior surface (superficial) level:
    • Defensive qi (wei qi)
    • Nutritive qi (nutritive qi; ying qi)
  • Organ/inside (interior) levels:
    • Vital essence or essential qi (zhen qi) and qi in general, and blood (blood is sometimes treated as a separate but related component)
  • Lower portion (yin/yang on a broader scale):
    • Yin and Yang in deeper layers, including kidney yin and kidney yang
    • Additional factors such as body fluids and essence, which are closely related to marrow and gynecological function
  • Relationship between qi and body fluids: qi governs and transforms fluids and blood; yang qi and qi jointly regulate body fluids and essence; fluids and essence are separate but closely linked components.
  • Quick mental map used in class:
  • Surface level: wei qi (defensive) and ying/ying qi (nutritive) on the surface; inner/organ level: qi, blood; lower level: kidney yin/yang; fluids and essence are also in play; all interact with the three pairings of yin/yang on different layers.
  • Practical take-away: deficiencies or excesses in any of these upright energies can manifest across the body, and diagnosing requires looking at multiple levels and how they interact.

• Etiology and pathogenesis (how upright qi is depleted; how pathogens arise)

  • Initial causes of upright qi depletion (etiology):
  • Dietary irregularities (e.g., snacking or overworking digestion) can exhaust stomach qi and spleen qi.
  • Emotional strain (anger, stress) that disrupts blood flow and organ function through neuroendocrine pathways.
  • Excess activity: sexual activity, heavy physical activity, late nights, screen exposure; overwork damages upright qi.
  • Chronic illness: pathogens persist in membranes and tissues, consuming energy and reducing upright qi and body fluid balance.
  • Additional contributing factors:
  • Overuse of eyes from screens can influence blood and qi distribution; muscular/pulse changes may indicate deficiency patterns.
  • How deficiency patterns arise: due to ongoing pathogenic exposure and sustained depletion of upright qi, especially when the body cannot replenish qi and blood (e.g., after prolonged illness, poor nutrition).
  • Treatment-oriented observations:
  • Provide practical lifestyle and dietary guidance to restore upright qi: avoid cold drinks, reduce snack intake, intermittent fasting to clear waste, easy-to-digest foods, and targeted changes to reduce dampness and stagnation.
  • The role of overwork and lifestyle: control over emotional and physical exertion, sleep, and screen time to protect upright qi.

• Pathogenesis mechanics: excess vs deficiency in a dynamic system

  • In disease, excess and deficiency are not mutually exclusive; both can occur in different sites or at different times in the body.
  • When assessing pathology, consider how fast a pathogen is exerting influence (acute) vs how long a deficiency has persisted (chronic).
  • Example dimensions discussed:
  • Acute exterior excess (e.g., sudden cold, wind invasion) vs chronic interior deficiency (e.g., prolonged spleen qi deficiency).
  • Arthritis example: after rest, pain worsens (an excess pattern in local dampness), whereas after activity, pain may improve; indicates an excess pattern with potential local dampness rather than a pure deficiency.
  • Treatment implications:
  • Exterior/excess patterns are treated by expelling the pathogen (cupping, bleeding, promoting urination to remove dampness).
  • Interior/deficiency patterns are treated by tonifying upright qi (nourishing qi, blood, fluids).
  • In mixed patterns (excess with deficiency): treat both sides, balancing the degree of tonification and expulsion; this often requires nuanced dosing and point selection.
  • Priority rules in mixed patterns:
  • If the excess is the dominant problem (e.g., acute infection with strong pathogen), treat the excess first while not neglecting deficiency.
  • If deficiency is dominant (e.g., chronic illness with poor constitution), tonify while gradually addressing the excess.
  • When both are equally evident, design a balanced approach that strengthens upright qi while also addressing the pathogen.
  • Concept of transformation: deficiency and excess can influence each other over time; patterns are not static and can evolve with treatment and disease progression.

• How to distinguish deficiency vs excess in practice (with specific signs)

  • Core indicators:
  • Deficiency signs: shortness of breath, shallow respiration, spontaneous sweating, weak voice (lung qi deficiency); abdominal distension with cold limbs (spleen qi deficiency); dizziness or pale complexion, fatigue, loose stools—varies by organ involvement.
  • Excess signs: strong, resistant pulse; aversion to cold (exterior cold); sweating with exertion (exterior contracture); pain that is localized, stabbing, or fixed; heat signs if heat pathogen is present; dampness or phlegm signs such as heaviness, distension, etc.
  • Case-based logic:
  • In a mixed case like arthritis with prolonged symptoms, consider both deficiency signs (stagnation, fatigue, weak pulse) and excess signs (pain, obstruction of flow, local dampness) and tailor the treatment to address both simultaneously.
  • Practical diagnostic triad: combine history, tongue, and pulse data to identify true patterns; beware of false impressions such as dampness masquerading as deficiency (false deficiency).
  • False deficiency (dampness): present as emaciated-looking signs due to external dampness or damp-heat, with heavy limbs, bloating, and languid manner; not a true deficiency of upright qi.
  • False excess: signs that look excessive on the surface but are due to other hidden deficiencies or misinterpretation of tongue/pulse.

• Tongue, pulse, and history as diagnostic anchors

  • Tongue: color, coating, moisture, and coating thickness can differentiate patterns (e.g., red with thick yellow coating suggests heat with damp-heat; pale tongue suggests blood or qi deficiency; tongue body and coating provide clues about interior heat, dampness, or stagnation).
  • Pulse: depth, strength, and quality (e.g., hollow, rapid, slippery, or excessive) help discern whether there is true deficiency or true excess and at what level (pulse depth often suggests internal vs surface patterns).
  • History and chief complaint: onset, triggers (e.g., food, weather, activity), evolution over time, and previous treatments; history helps distinguish primary/true patterns from secondary or transient patterns.
  • The speaker emphasizes that no single sign suffices; the deepest diagnosis requires combining tongue, pulse, history, and chief symptom patterns.

• Treatment principles in context of yin/yang and interior/exterior dynamics

  • Exterior/excess patterns: expel the pathogen while protecting the body’s core (e.g., cupping, bleeding, promoting urination, dampness clearance).
  • Interior/deficiency patterns: tonify upright qi, nourish Yin, blood, and fluids; support organ function.
  • In mixed patterns, the treatment plan must balance both aspects, avoiding over-correction that could deplete the patient’s resources.
  • Yin-yang balance as a guiding framework:
  • When heat is present (yang) but yin is deficient, treatments should cool or clear heat while nourishing yin to restore balance.
  • If dampness (a kind of stagnation or obstruction) is present with deficiency, strategies should both drain dampness and tonify the constitution.
  • Practical cautions:
  • Overly aggressive treatment (e.g., heavy sweating or purging) can deplete upright qi and worsen the underlying deficiency; always monitor and adjust.
  • Use a measured approach, starting with milder interventions and escalating only if necessary, and adjust based on patient response.

• Case study framework: Allergies with hives (example exercise)

  • Chief complaint: Allergies with hives, morning sneezing, itchy eyes; onset two weeks ago; external signs include red face and aversion to cold; nasal symptoms with clear discharge; eyes red.
  • Diagnostic interpretation (as discussed in class exercise):
  • Exterior/excess indicators: aversion to cold, nasal discharge, itchy eyes, possible wind path causing sneezing and hives; exterior signs are prominent.
  • Possible interior deficiency indicators: headaches around PMS, possibly blood or qi deficiency signs in other domains; poor appetite and dampness symptoms noted in some contexts.
  • Heat signs: red face and eye irritation suggest heat involvement; heat may be stagnant or interior with dampness.
  • Pattern conclusion (illustrative): exterior excess pattern with interior deficiency components (mixed pattern). The recommended approach is to treat the exterior and also nourish interior qi/blood to support defense and reduce susceptibility to pathogens.
  • Therapeutic strategy: combine exterior-dispelling approaches with interior tonification, aiming to clear the exterior pathogen while strengthening upright qi to resist future invasions.
  • Practical pointers for this type of case: look for triggers, observe the evolution of symptoms, and assess tongue + pulse to confirm pattern; avoid relying on a single sign.

• Practical case analysis tips and common pitfalls

  • Don’t rely on a single symptom to define a pattern; use the eight principles and the triad of tongue, pulse, and history to triangulate.
  • Remember that patterns can transform: an excess pattern can become deficient if prolonged pathogenesis exhausts upright qi; a deficiency pattern can be worsened by ongoing pathogenic exposure.
  • Clues from specific conditions help with pattern differentiation:
  • Lung qi deficiency signs: shortness of breath, spontaneous sweating, weak voice.
  • Spleen qi deficiency signs: abdominal distension, poor digestion, cold extremities, possible dampness.
  • Kidney qi/yuan qi issues: lower back soreness and fatigue; dizziness; tinnitus; menstrual/urinary issues depending on pattern.
  • Blood deficiency signs: pale tongue, night sweats, insomnia, dizziness; pale complexion and fatigue; inability to nourish tendons and tissues; potential for wind signs (tendon spasms) when blood fails to nourish the body.
  • Blood stasis signs: stabbing chest pain; fixed masses or nodules; rough palpation findings; impeded circulation.
  • Dampness-related caveats: dampness can create “false deficiency” appearances; damp-heat often appears as heat signs with heaviness or fatigue, but it is an excess pattern and requires expulsion of dampness and pathogens rather than mere tonification.
  • Distinguishing true deficiency vs false deficiency: combine tongue, pulse, and patient history to avoid mistaking damp-heat or dampness with a perceived deficiency.
  • The value of a nuanced approach: even when a patient presents with many deficiency indicators, there may still be an underlying excess pattern; misinterpretation can lead to poor outcomes if you tonify when you should clear damp heat or expel pathogens.

• Yin and yang as a practical framework for diagnosis and treatment

  • Yin and yang provide a macro-structure that informs the smaller pattern differentiations (qi, blood, fluids, essence, and organ pattern interactions).
  • Exterior vs interior is a primary axis for disease location; heat vs cold marks a quality axis; deficiency vs excess marks a strength axis; and yin vs yang anchors the balance in the body’s overall energy state.
  • The same principle is applied across multiple layers (defensive qi, nutritive qi; organ qi and blood; fluids and essence; and deeper lattice involving kidneys and marrow).
  • Practical usage:
  • If heat is present on the exterior (yang) versus interior (yin) determines whether to disperse heat on the exterior channels or nourish yin to cool interior heat.
  • If there is urinary or lower-jiao dampness, consider both external clearance and interior tonification to restore systemic balance.
  • The instructor emphasizes continual practice with patterns rather than memorized formulas: you should understand what is directly causing symptoms (the immediate pathogen or imbalance) and what lies behind it (the root deficiency or exhaustion of upright qi).

• Final cautions and integration for exam-ready knowledge

  • The eight principles are a comprehensive diagnostic framework; they are not a set of rigid rules but a structure for consistent reasoning.
  • Real clinical work often involves mixed patterns; the skill is to identify the dominant pattern(s) and to design a balanced treatment that addresses both deficiency and excess where needed.
  • Do not dichotomize every case into purely excess or purely deficiency; use history, tongue, pulse, and manifestations to determine the dominant and supporting patterns.
  • Practice with case studies to internalize the process (onset, trigger, preference) and to better differentiate true patterns from false ones.
  • The teacher encourages continuous practice and reflection, acknowledging that even practiced clinicians refine their diagnostic approach over time.

• Summary takeaways

  • Eight Principles framework (Exterior/Interior, Cold/Heat, Deficiency/Excess, Yin/Yang) is the core diagnostic scaffold.
  • Deficiency = insufficiency of upright qi; Excess = exuberant pathogenic qi. Both can co-exist and shift positions over time.
  • Pathogenesis includes six external pathogens with transformations (dampness, phlegm, turbidity, toxins, blood stasis) and the concept of toxins as necrosis in tissue.
  • Upright qi and nine energies span surface-level defenses to interior organ-level qi and fluids, with kidney yin/yang and essence playing crucial roles.
  • Etiology includes diet, emotion, overactivity, and chronic illness; management includes lifestyle adjustments and targeted therapy to tonify upright qi or expel pathogens.
  • Deficiency and excess must be evaluated together, with attention to primary vs secondary patterns and to the patient’s overall energy state.
  • Tongue, pulse, history, triggers, and chief complaint are all essential diagnostic tools; avoid relying on any single sign.
  • Yin-yang balance guides treatment choices; in mixed patterns, adopt a balanced approach that does not over-correct in one direction.
  • Finally, practice with cases to sharpen your ability to distinguish patterns, recognize transitions between deficiency and excess, and design safe, effective treatment plans.

• Notes on terminology used in class (for quick reference)

  • Deficiency = insufficiency of upright qi; Excess = exuberance of pathogenic qi.
  • Pathogenic qi types include wind, cold, heat, dampness, dryness, toxins; dampness can transform into phlegm and turbidity; toxins can be tissue-damaging necrosis.
  • The nine upright energies include defensive qi (wei qi), nutritive qi (ying qi), zhen qi, qi, blood, yin, yang, fluids, and essence; with the kidneys involved in yin/yang balance and marrow-related functions.
  • False deficiency/false excess refer to misinterpretation when dampness or heat misleads the diagnostic process; look for tongue and pulse corroboration.
  • The case-study framework emphasizes triggers, preference, and onset as key diagnostic weights; however, tongue and pulse remain decisive anchors.

• Ethical and practical implications (brief reflection)

  • The teaching highlights humility in diagnosis: patterns are dynamic and multifactorial; experienced clinicians continuously refine their understanding rather than rely on rigid labels.
  • The approach encourages careful, patient-centered assessment (history, triggers, tolerances) rather than hasty conclusions.
  • The balance between expelling pathogens and tonifying upright qi reflects a practical, resource-conscious framework for patient care, aiming to restore health while preserving vitality.