《内经》情志致病理论研究

【作者】 杨巧芳；

【导师】 孟庆刚；

【作者基本信息】 北京中医药大学 ， 中医基础理论， 2009， 博士

【摘要】 《黄帝内经》是中医经典医籍之最,其内涵博大精深,多少年来一直为中医学界乃至其他学科人士研究不辍。《黄帝内经》中有许多情志致病的相关论述,形成了情志致病理论的雏形,经历代医家的补充和发挥不断完善。基于当今社会情志病发生率逐年增高的现实,情志病因在疾病发生中的重要作用更加突出,情志致病理论越来越受到医家的高度重视。本课题以理论思维为主导,结合数理统计分析,综合运用文献学、医案学、诠释学和多学科交叉等研究方法,对《内经》情志致病理论进行系统整理并有所发挥。包括:对《内经》情志致病理论相关原文分类整理、诠释;以全书、类书及现代文献等为索引从浩如烟海的中医古代医籍中发掘出历代医家对情志致病理论的理解和发挥,并按年代梳理其特点和特色;以《二续名医类案》为资料来源库进行医案分析,从医案学的角度总结情志致病的规律和特点;结合现代文献和自己在生活中的体验对《内经》情志致病理论进行现代诠释;以认知心理学为基础从多学科交叉的角度对《内经》情志致病理论做进一步的深入探讨。本文主要分为三个部分:第一部分为情志基础理论阐释。从情志的字源学含义开始,引入对医学概念的理解,从情志的类别、特性,到情志的发生机制以及与健康的关系,结合情志与情绪的区别和联系以及现代心理学情绪理论,对情志的概念和特性进行充分的分析和界定,为情志致病理论的研究奠定概念学基础。情志是中医学对人类情绪的特殊界定和理解,是以七情为基础的情绪活动的总体概括,与现代心理学情绪的内涵既有区别也有联系。把“思”认为是基础情志之一,表明情志不仅仅是简单的情绪反应,而是在认知基础上的情绪情感过程。人与生俱来具有一定的情志表达能力,一定的情志表达对人的身心和谐具有正向的调节作用,若超过一定的限度,则会对身心造成伤害。情志由于其表达方式及对人体的影响作用不同等分为良性情志和不良情志、经意情志和不经意情志、勃发情志和持续情志,并具有能量性、两极性、双重性和兼挟性等特性,这些特性与情志致病有一定的联系,在某种程度上是情志能够致病的重要原因之一。第二部分是研究现状分析。全面分析目前情志致病理论的研究现状,发现存在的问题和不足,并以此为依据确立本课题的研究角度和方法。实验研究方面虽然以广州中医药大学徐志伟等、成都中医药大学王米渠等为代表的医家在实验研究方面取得一定成绩,但仅仅局限在怒志和恐志的研究。且由于情绪的复杂多变性,难以复制出可靠的、被普遍认可的动物模型,使得实验研究的难度增加,研究结果的可信度较差。理论研究方面多局限在中医基础理论本身的理解,且内容重复较多,虽然中国中医科学院的刘洋对情志病因进行文献整理和研究,但主要是基于《内经》对怒志的研究,目前尚无对情志致病理论的古今文献系统整理以及从多学科交叉角度的理论探讨。基于此,确立了本课题的研究角度与方法,即继承与发展相结合,在系统整理《内经》情志致病理论古今文献的基础上,从多学科交叉的角度基于认知心理学对《内经》情志致病理论有所发挥。第三部分是研究的主要内容。从五个不同的方面对《内经》情志致病理论进行整理、挖掘和发挥。即:1.《内经》情志致病理论原文整理仔细阅读《素问》和《灵枢》,从原文中逐条摘录情志致病的相关条文,参阅历代注家解释和现代文献资料,按照七情致病、多情交织致病、其它情志致病以及与情志致病相关的因素和其传变规律进行分类总结、整理和诠释。整理发现《内经》中有许多情志致病理论的相关论述,内容包括情志致病的规律、特点、社会因素、传变规律、致病病种、致病机理等等各个方面,已经形成了情志致病理论的雏形。2.梳理历代医家对《内经》情志致病理论的诠释和发挥从历代众多的医家中筛选出对《内经》情志致病理论有所发挥的医家,如唐代注家王冰、宋代的陈无择、金元时期的刘完素、张子和、李东垣、朱丹溪、明代的张景岳、李中梓以及清代的叶桂、沈金鳌、费伯雄等医家,分别从其主要著作中摘录出代表各医家主要观点的原文,总结出各医家对情志致病理论理解、发挥的特点和特色。例如:王冰的“五志甚则自伤,过用病生”、陈无择的“七情为内所因,各随本脏所伤”、刘完素的“情之所伤,皆属火热”、张子和的“五志所发,皆从心造”、李东垣的“七情所伤,皆损元气”、朱丹溪的“人身诸病,多生于郁”、张景岳的“情志之伤,从心而发”、李中梓的“妇人之病,易伤七情”、叶桂的“七情之郁,总由乎心”、沈金鳌的“七情之伤,发而过其节也”、费伯雄的“七情之伤,必归于心”等等。3.医案整理研究以《二续名医类案》为资料来源库,以EXCELL数据库为统计工具,对清代中叶到建国初期名医医案进行整理分析。研究以明确记录有情志病因的医案为纳入标准,并剔除情志非致病因素而是作为疾病症状出现者。以手工检索的方式,逐个翻阅医案,同时对医案中的相关描述进行规范化处理,以页码、医案、医家、性别、七情、病名、科别等录入表格,分类计数处理,结果发现七情在不同性别、不同科别、不同病种、不同医家病案中的分布规律有所差异。表述如下:(1)喜作为致病因素在医案中没有提及,七情病因相关病例中尤以“怒”志例数最多,“思”、“惊恐”次之,“悲”、“忧”例数最少,说明怒志在情志致病中尤为突出。(2)情志病因医案中女性患者比男性患者较多,我们认为女性可能较男性更易罹患情志病,正如《千金要方》曰:“妇人嗜欲多于丈夫,感病倍于男子,加以慈恋、爱憎、嫉妒、忧忿,染者坚牢,情不自抑”。(3)男女疾病相关的首要情志均为怒志,除怒志外,男性以“思”、“惊恐”为主要致病情志因素,女性以“悲”、“忧”为主要致病情志因素。(4)情志病因在男性科中出现频率最高,其次是内科疾病,儿科疾病受情志影响最小。其中内、妇、外、耳鼻喉等科以“怒”志为主要情志病因,而男科和儿科以“惊恐”为主要情志病因。(5)内科各系统中,受情志因素影响最大的是心系,其次是脾胃系统。心系以“思”、“惊”两志例数最多,肝胆以“怒”志例数最多,印证了《内经》“心怵惕思虑则伤神”、“怒伤肝”的相关论述。(6)七情病因在不同的疾病中分布不一,血证、腹痛、噎膈、厥证以“怒”志损伤为主,癫狂、心悸怔忡以“惊恐”损伤为主,咳嗽以思伤为主,郁证以复合情志损伤为主。(7)不同医家所诊治的病例中,七情病因的分布有所区别,从中可一定程度上反映出医家对情志病因的重视程度,例如张锡纯尤其重视思伤在情志致病中的重要位置。基于以上研究结果,我们总结出情志致病的总体规律和特点为:“情志致病,病种广泛”、“情志致病,怒志为首”、“七情致病,各有所伤”、“情志致病,易伤心神”,并联系当今社会现实情况,认为思伤在情志致病中具有重要的现实意义。4.《内经》情志致病理论现代诠释基于对文献资料的理解和自己在生活实践中的体验,对《内经》情志致病理论进行诠释和理解。(1)认为情志致病是以体质为核心的恶性循环链的启动,是情志与脏腑失和的表现形式,其主要病理机制为气机紊乱,其发生受多种综合因素的共同影响,如自身因素、自然因素、社会因素等等。(2)总结出伤气、伤血、伤脏、伤神等情志致病的途径与方式。气是构成人体的最基本物质,气的运动维持人的生命活动,情志刺激容易扰乱气机的升降出入运动或消耗元气而患病;血是构成人体生命机能的基础物质之一,全身血脉与心相通,“流行不止,环周不休”,从而维持生命的正常功能活动,情志可导致血液瘀滞或耗损人体精血为病;情志出于脏腑,赖脏腑的精血濡养而正常表达,可以“五志伤五脏”、“从心而发,伤及他脏”及“多情交织共同致病首先伤肝”等多种方式直接损伤人体的脏腑而为病;情志亦可直接伤及心神,神乱而为病。(3)提炼出情志致病的环节理论:体质虚弱是情志致病的核心,外界刺激是情志致病的扳机,情志异常是情志致病的中心环节,认知是刺激引起情志异常继而致病的重要过程。5.基于认知的《内经》情志致病理论研究对认知与情志(情绪)的关系进行梳理,认为认知是情志发生的一个重要过程,认知图式、认知偏向、认知失调是导致情志异常继而致病的重要原因。(1)认知的含义及其与情志的关系认知是大脑对外界信息的加工处理过程,认知过程即是指信息输入到内部加工再到信息输出的全部过程。先秦哲学把认知过程分为知与虑即感知与思维两个阶段,《内经》对认知过程的论述则主要集中在《灵枢·本神》篇,提出“天之在我者德也,地之在我者气也,德流气薄而生者也。故生之来谓之精,两精相搏谓之神,随神往来者谓之魂,并精而出入者谓之魄,所以任物者谓之心,心有所忆谓之意,意之所存谓之志,因志而存变谓之思,因思而远慕谓之虑,因虑而处物谓之智”。我们认为,任物是认知的基础,意志是认知的重要环节,思虑是认知的核心,智是认知的最高境界,五神藏是认知的重要脏器。情志中本身含有认知的内涵,认知是情志发生的重要环节,认知对情志具有一定的调节作用。(2)认知在情志致病中的重要作用认知图式是指对认知系统的一种模拟描述,认知图式随个人的生活经历而不断地更新和变化,皮亚杰称之为同化和顺化。认知的主要器官人脑与计算机相似,五官感知输入外界刺激经大脑进行信息加工,图式即相当于计算机的程序,不同的认知图式加工结果会大相径庭,良性的认知图式倾向于输出良性的结果,而不良的图式倾向于输出不良的结果。所以,不同的认知图式对情志形成有不同的影响,是导致情志异常的原因之一。图式还会对外界刺激信息进行有选择偏向的加工,这种偏向反应在编码、理解和信息提取过程中,即对图式一致性的信息更受欢迎,如拥有焦虑图式者易于加工威胁性的信息,这种病理性的认知偏向容易形成负性情绪反应。认知失调是指认知元素之间的不协调的关系,认知不协调容易引起个体本身的心理冲突,使身心容易敏感导致易激惹状态,使人对异常情志反应的阈值降低,容易引起不良情绪的产生。总之,我们从文献整理入手,首先厘清情志的基本概念和内涵,继而对《内经》条文进行整理,并予以合理的解释,结合历代医家的发挥、医案整理分析和现代文献对《内经》情志致病理论进行现代诠释,并在此基础上,从多学科交叉的角度基于认知心理学对情志致病理论做进一步的深入探讨,提炼出情志致病的“环节”理论以及认知之于情志致病的重要作用原理。中医学是实践的科学,临床是基础理论发展的动力和源泉,而理论的研究则能为临床提供指导服务。情志致病理论的深入研究有利于促进用科学的方法引导情志“当发而发”、“发而有节”,为临床治疗和养生应用提供有益的帮助。更多还原

【Abstract】 "The Medical Classic of the Yellow Emperor" is one of the earliest existent medical classic in china,whose connotation is extensive and profound,and studied continuously for the medical arena and even other discipline for many years.Much relevance about emotions to cause disease is discussed in "The Medical Classic of the Yellow Emperor",which has formed embryonic form of the emotions pathogenesis theory,and developed and consummated unceasingly by the ancient medical scientist.Based on the reality which emotions sickness formation rate advances by years,emotions pathogen will be more prominent in modern society,the emotions pathogenesis theory is valued for many medical scientists more and more.We take literature study,medical notes study,hermeneutics and multi-disciplinary overlapping and so on as fundamental research method in this text,to extract related article one by one with the emotions pathogenesis theory,and classify,reorganize,and annotate them; take the entire book,a kind of book and the modern literature and so on as the index,to extract understanding about the emotions pathogenesis theory for all previous medical scientists,and combed its characteristic according to the age;take "The third Famous doctor Class Document" as the data source storehouse,to analysis and summarize the emotions pathogenesis’ rule and characteristic;to carry on the modern annotation by the life experience; take the cognition psychology as the foundation to make the further thorough discussion for the emotions pathogenesis theory from the multi-disciplinary overlapping angles.The paper text is mainly divided three parts:The first part is emotions basic theory explanation.We start from the emotions’ character meaning,to introduce the medicine concept understanding,from the emotions’ category,the attributes,to the emotions’ occurrence mechanism as well as with the health relations,the emotions and the mood difference and contacting and the modern mood theory,to carry on the full analysis and the limits to the emotions’ concept and the characteristic,as the concept study foundation for the research of emotions pathogenesis theoryThe second part is the present situation analysis.We analyze comprehensively research present situation about emotions’ pathogenesis theory,in order to discover the existent question and insufficiency.In the experimental study aspect,because of the mood’s complex polytropy,it is difficult to duplicate reliable animal model which approves generally,and make the confidence level of the experimental study result to be bad;In fundamental research aspect, it is limited in Chinese medicine basic theory’s understanding,and include many redundant contents,we did not find the ancient and modern literature system reorganization as well as from the multi-disciplinary overlapping angle theory discussions at present.Based on this,we have established this topic’s research angle and the method,inherit unifying with development, To reorganize system the emotions’ pathogenesis theory ancient and modern literature,to develop emotions’ pathogenesis theory based on cognition psychology from multi-disciplinary overlapping anglesThe third part is the research primary context.We carried on the reorganization,the excavation and the display separately from five different aspects to emotions’ pathogenesis theory:1.Emotions’ pathogenesis theory original text reorganization.We read carefully "The Medical Classic of the Yellow Emperor",and extracted one by one the emotions’ pathogenesis related article from the original text,and to summarize,reorganize and annotate according to the seven emotions pathogenesis,other emotions’ pathogenesis as well as with the emotions’ pathogenesis correlation factor2.We comb the annotation and the display of emotions pathogenesis theory for all previous dynasties medical scientists.From Wang Bing in Tang Dynasty,Song Dynasty’s Chen Wuze,Liu Wansu,Zhang Zihe,Li Dongyuan,Ming Dynasty’s Zhang Jingyue,Li Zhongzi to Qing Dynasty’s Ye Gui,Shen Jinao,Fei Boxiong and so on,we extracted separately the major point in the original text to represent the various medical scientists,summarized the characteristic.3.We take "The third Famous doctor Class Document" as the data source,take the EXCELL form as the tool,reorganize and analyze the famous doctor medical notes from the Qing Dynasty middle period to the early years of the new nation,and discovere that seven emotions distribute differently in the different sex,the classmate,the different sickness,the different medicine medical record,and summarize four rules and the characteristic about emotions pathogenesis,think that th inks of the wound to be important in the emotions’ pathogenesis.4.The emotions pathogenesis theory modern annotation.Based on the literature material’s understanding and the life practice’s experience,summarize emtions pathogenesis ways;And think that the physique is the core of emotions’ pathogenesis,the stimulation is the trigger,the exceptional emotions is the center link,the cognition is the important process.5.We study the emotions’ pathogenesis theory from the cognition angle,comb relations of the cognition and emotions(mood),think that the cognition is an important process which the emotions occurs,and the cognitive schema,the cognition deviation,cognition being out of balance cause the exceptional emotions which is important reason of the emotions’ pathogenesisIn brief,we begin to work from the literature reorganization,and at first define clearly the emotions’ the basic concept and the connotation,subsequently carry on the reorganization to the article in "The Medical Classic of the Yellow Emperor",and give the reasonable explanation,and unify all previous dynasties medical scientists’ viewpoint and the medical notes reorganization analysis and the modern literature to the emotions pathogenesis theory carry on the modern annotation,make the further thorough discussion from the multi-disciplinary overlapping angles based on the cognition psychology,summarize the emotions’ pathogenesis "the link" the theory as well as the emotions’ pathogenesis influential principle about cognitionThe traditional Chinese medicine is the practical science,clinic is development power of the basic theory,to study deeply the emotions pathogenesis theory is beneficial to guiding the emotions with the science method,which provided the help for clinic and the keeping in good health.更多还原