A Series in Integrative Medicine

Traditional Tibetan Medicine A Concise Overview

James Lake, MD and

Rogier Hoenders, MD , PhD Moderator: Ronald Glick, MD

January 23, 2014

Jointly sponsored by Vanderbilt University School of Medicine Department of Medicine, Division of General Internal Medicine and Public Health

and the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM)

After participating in this CME activity, participants should be able to describe and discuss how to:

• Engage their patients with a holistic and collaborative approach to healing

• Refer patients with chronic illness and chronic pain to appropriate integrative modalities for care

• Use basic coaching and motivational interviewing skills to engage healthy behavior change

AMA Objectives

APA Objectives

After participating in this CE activity, participants should be able to:

• State an understanding of the basic philosophical approach, cause of pathology, and common treatment approaches to Tibetan Medicine as a whole medical system

• Identify specific lifestyle and treatment approaches that may be applied in Traditional Tibetan Medicine to treat metal health problems

• Identify three principles of Traditional Tibetan Medicine that are relevant to mental health

Target Audience

Physicians, Psychologists and other health professionals from the United States and Canada who are members of the

Consortium of Academic Health Centers for Integrative Medicine.

Instructional Level Intermediate

Disclosures It is the policy of Vanderbilt University School of Medicine and the Consortium of Academic Health Centers for Integrative Medicine to require the disclosure of financial relationships from individuals in a position to control the content of a CME activity; to identify and resolve conflicts of interest related to those relationship; and to make disclosure information available to the audience prior to the CME activity. Presenters are required to disclose discussion of unlabeled/unapproved uses of drugs or devices during their presentations.

Course Director: Gurjeet Birdee, MD, Assistant Professor in Internal Medicine and Pediatrics at Vanderbilt University School of Medicine

Planner: Tobi Fishel, PhD, Associate Professor in the Departments of Psychiatry, Psychology and Pediatrics at Vanderbilt School of Medicine

Planner: Jeff Feldman, PhD, Assistant Professor of Neurology at Wake Forest Medical Center

Planner: Amy Locke, MD, Assistant Professor in Department of Family Medicine at University of Michigan Medical School

Speaker: James Lake, MD, Chair Emeritus of the International Network of Integrative Mental Health and Psychiatrist at Monterey VA Clinic

Speaker: Rogier Hoenders, MD, PhD Integrative Psychiatrist, Founder and Director of the Center for Integrative Psychiatry in Lentis, Netherlands.

Moderator: Ronald Glick, MD, Asst. Professor Dept. of Psychiatry and Physical Medicine and Rehabilitation at University of Pittsburg

All course directors, planners and speakers have no financial relationships to disclose.

This educational activity received no commercial support.

CME Credit This activity has been planned and implemented in accordance with the Essential Areas and

Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Vanderbilt University School of Medicine and the Consortium of Academic Health Centers for Integrative Medicine. Vanderbilt University School of Medicine is accredited by the

ACCME to provide continuing medical education for physicians.

Vanderbilt University School of Medicine designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the

extent of their participation in the activity.

CE Credit Vanderbilt School of Medicine is approved by the American Psychological Association to sponsor

continuing education for psychologists. Vanderbilt University school of Medicine maintains responsibility for this program and its content.

Vanderbilt University School of Medicine designates this educational activity for 1.0 CE credits toward the continuing education of psychologists.

No partial credit may be awarded.

Credit Requirements This CME/CE activity consists of a simultaneous Power Point presentation and conference call followed by an evaluation, and will require approximately one hour of your time.

To obtain CME/CE credit for your participation in this activity, you must:

• View the entire presentation.

• After the call, submit to Marina Kaasovic at mkaasovi@umn.edu , your name and the phone number you called in from for today’s program.

• You will receive an evaluation form and contact form to be completed and returned within 7 days after the CME/CE session.

• Once your CME certificate is available you will receive an email notification from CME@Vanderbilt.edu with log-in information to the CME Website. By following the email instructions, you may retrieve your certification.

• If you do not receive anemail notification, please check your spam/junk folder before contacting CME or Marina Kaasovic.

• Personal information is used for issuing a CME or CE credit certificate and storing that credit in the Vanderbilt OCPD database.

If you have questions or need additional information contact Marina Kaasovic at mkaasovi@umn.edu

Americans with Disabilities Act

It is the policy of Vanderbilt University School of Medicine and the Consortium of Academic Health Centers for Integrative Medicine not to

discriminate against any person on the basis of disabilities.

If you feel you need services or auxiliary aids mentioned in this act in order to fully participate in this continuing education activity, please

speak with a course director or planner.

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TRADITIONAL TIBETAN MEDICINE A CONCISE OVERVIEW

Consortium Clinical Working Group Integrative Mental Health 23 January, 2014

James Lake M.D. www.IntegrativeMentalHealth.net

Medical Education

Biomedicine Tibetan medicine

Different fields within the health care system

Team work

Doctor Nurse Therapist

Tantra (तन्त्र) or rgyud (རྒྱུད།):

Lineage of Teaching

Methods of study

Physician

Theory…

Biomedicine Tibetan Medicine

Basic Sciences Anatomy

Physiology

Pathology

Clinical Studies Internal medicine

Pediatrics

Obstetrics & Gynecology

Psychiatry

Surgery

First & Second Tantra Display of the body

Body functions

Conditions of diseases

Third Tantra Body as a whole

Children’s disorders

Women’s disorders

Disorders caused by spirits

Injuries

Energies in TTM

རླུང་།

rlung

Wind

Literally ‚motion‘

བད་ཀན།

bad kan

Phlegm

Literally ‚dew & earth‘

མཁྲི་པ།

mkhris pa

Bile

Literally ‚burning‘

Life-sustaining wind in the ocean of channels

Inner liquid and solid elements

Metabolic heat in the small intestine

Brainwaves

Body cells

Digestion

Pathologic Basis of Diseases

Biomedicine Tibetan Medicine

Metabolic

Inflammatory

Degenerative

Neoplastic

Infectious

Traumatic

Psychological

Cold natured

Hot natured

Cold natured

Self-originated

Caused by srin

Caused by weapons

Caused by provocations

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=

=

=

=

=

=

Therapy

Biomedicine Tibetan Medicine

Treatment of the physical body

Chemistry and technology

Advantages

Standardized treatments

Strong physical effects

Proven efficacy

Limitations

Dependence on technology

Side effects

High expenses/environmental impact

Rebalancing energy

Natural resources

Advantages

Self-administered treatments

Fewer side effects

Less costly/lower environmental impact

Limitations

Difficult to get required training

No standardized treatments

Not evidence based

TRADITIONAL TIBETAN MEDICINE

Mental health and mental illness

Mental Health

& Mental Illness

What is good mental health?

Biomedicine Tibetan medicine

Psychological well-being

Absence of a mental disorder

WHO: state of well-being Realization of one‘s abilities

Coping with normal life stresses

Productive and fruitful work

Contributing to community

Expression of emotions

Enjoyment of life

Balance between life activities and efforts to achieve psychological resilience

Balance of body, mind & energy

good health & long life Dharma

Wealth

Happiness

Ultimate realization of mind

spiritual enlightenment

Mental Disorders

Biomedicine WHO: ICD-10

Tibetan Medicine & Buddhist Psychology

F0 Organic disorders

F1 Substance use

F2 Psychotic disorders

F3 Mood disorders

F4 Neurotic and somatoform disorders

F5 Behavioral disorders + physical disorders

F6 Personality disorders

F7 Mental retardation

F8 Disorders of psychological development

F9 Behavioral and emotional disorders with early onset

79 Dementia

80 Planetary provocations

• Destructive emotions

78 Madness provocations

34 Snying rlung disorders

81 Naga provocations

77 Element provocations

77 Element provocations

• Karmic disorder

73 Children’s provocations

73 Children’s provocations

Depressed mood—etiology Biomedicine Tibetan Medicine

Etiology Personality Life events Social causes Physiological causes Other syndromes

Diet Lifestyle Seasons Provocation

Pathophysiology Emotional or cognitive disorder Hormonal/neurotransmitter imbalance Structural brain changes

སྲིང་རླུང་། (snying rlung) Energy

imbalance of the heart Destructive emotions imbalance of the mind

Divisions & Symptoms Depressed mood Fatigue

Feeling empty Mania

Insomnia Increased appetite

Cyclic mood changes

Bad kan disorder Heavy or dull mind Sadness

Mkhris pa disorder Active mind Increased digestion

Rlung disorder

Depressed mood—assessment Biomedicine Tibetan Medicine

Diagnosis History Physical examination Lab results EEG, CT, MRI

Asking questions Pulse reading Urine analysis Dream analysis

Findings Symptoms Physical disorders (thyroid dysfunction, etc.) Hormonal imbalances Structural changes

Epilepsy Hyper or hypoactive brain areas

Signs Heart pulse

Rlung pathology Mkhris pa pathology Bad kan pathology

Provocation signs in urine Destructive emotions

Depressed mood—treatment Biomedicine Tibetan Medicine

Diet Depressive disorder: warming food Maniac disorder: cooling food Bipolar disorder: nourishing food

Psychotherapy Psychodynamic psychotherapy Cognitive behavioral therapy Other forms of therapy

Lifestyle Daily life (individual, social, spiritual) Seasons Physiology

Medicine Antidepressants Antipsychotics Sedative-hypnotics Stimulants

Medicine Herbal medicine Animal products Minerals & metals

External Therapies (viewed as CAM) • Yoga and taijichuan • Massage • Exercise • Chiropractic

External Therapies Depressive disorder: compress therapy, moxa Maniac disorder: blood letting, water therapy, acupuncture Bipolar disorder: ku nye massage, moxa

A Zen student asked his master, "Is it OK to use email?“

"Yes," replied the master, "But no attachments!“

Biomedicine Tibetan Medicine

Working With the Mind

Diet, lifestyle, medication, external therapies

Spirituality

Advantages

Familiar cultural background (law of cause and effect, karma)

Connection to nature

Limitations

High training required

Acceptance of karma

Medication

Psychotherapy

Advantages

Empirical knowledge and research

Practical clinical methods

Limitations

Medication side effects

Cost and availability

Taboo topic

INTERNATIONAL ACADEMY FOR TRADITIONAL TIBETAN MEDICINE

Traditional Production of Herbal Medicine

External Therapies & Materials

External Therapies & Materials

TTM Anywhere & For Anyone

Why is it important to preserve and promote TTM?

• Sowa Rigpa has existed on its own right as a unique highly evolved system of medicine since the 12th century

• Uses rigorous empirical methods and similar concepts of anatomy & physiology

• 80% of disorders are equivalent to Western disorders

• Unique assessment tools, preventive and therapeutic methods including diet, lifestyle, over 10,000 herbal formulas, external and spiritual therapies

• Adapts to Western medical theory and practice because of philosophical roots (Ten’drel); can be used by and for anyone regardless of ethnic, cultural, religious background

• May be safely combined with other medical systems

Why preserve TTM?

• TTM acknowledged by WHO as traditional Bhutanese and Traditional Mongolian Medicine however…

• TTM at risk of being misinterpreted

• Knowledge of TTM may be compromised due to political issues affecting Tibet

• The spiritual philosophy at the core of TTM is forbidden in Tibet

IATTM Activities

Regular IATTM courses in over 20 centers in America, Asia, Australia and Europe

Courses reach thousands of students include herbal medicines, external therapies and spiritual teachings

Online study opportunities increasing www.SorigInstitute.org

TTM study tours to Tibet with co-operation from:

Qinghai TTM University

Qinghai TTM Hospital

Mahlo Traditional Medicine Hospital

International TTM Congress, most recent in September 2013, Innsbruck, Austria

We must recognize that the suffering of one person or one nation is the suffering of humanity.

That the happiness of one person or nation is the happiness of humanity.

14th Dalai Lama

May all sentient beings be free of suffering

and the causes of suffering.

Books on Tibetan Medicine

• The Spiritual Medicine of Tibet, Pema Dorjee, Jones & Moore

• Healing Elements: Efficacy and the social ecologies of Tibetan Medicine, Craig

• Tibetan Medicine, Rechung Rinpoche

• Essentials of Tibetan Medicine, Thinley Gyatso & Chris Hakim

Books on Tibetan Medicine

• In Search of the Medicine Buddha: A Himalayan Journey, Crow

• Tibetan Buddhist Medicine and Psychiatry: The Diamond Healing, Clifford

• Mind in Tibetan Buddhism, Lati Rinpoche & Napper

• The Root Tantra and the Explanatory Tantra, Men-Tsee-Khang, Dharamsala