Stress and Irritability
F, 38 years old. Patient reports chronic stress, easy irritability and a sensation of tightness in the chest and hypochondriac region for the past 3 months.
The patient
- Age and sex
- 38 years · F
- Chief complaint
- Patient reports chronic stress, easy irritability and a sensation of tightness in the chest and hypochondriac region for the past 3 months.
- Tongue
- Slightly red body on the edges, with a thin white coating.
- Pulse
- Wiry (Xian) pulse, especially in the left Guan (關) position (Liver-Gallbladder).
Symptoms
- Irritability and frequent mood swings
- Sensation of a lump in the throat
- Bilateral costal distension and discomfort
- Frequent sighing
- Insomnia due to difficulty switching off
- Occasional temporal headache
Warning signs to rule out
- The lump sensation becomes real difficulty swallowing solids, or unintended weight loss appears. → Refer for digestive workup. Plum-pit qi is a sensation without objective dysphagia; if there is dysphagia, this is no longer the pattern.
- Right hypochondriac pain with fever, jaundice or vomiting. → Emergency care. Acute biliary disease must be ruled out before continuing to treat the picture as emotional.
- Persistently low mood, anhedonia or thoughts of self-harm. → Refer to mental health services without delay. Acupuncture accompanies treatment; it does not replace it.
Case resolution
Think through the pattern first, then expand the resolution
- Pattern
- Liver Qi Stagnation (Gan Qi Yu Jie)
- Meridians involved
- Liver, Gallbladder
- Pathogenic factors
- Qi Stagnation, Constrained Liver Qi
The Liver in TCM is responsible for ensuring the free flow of Qi throughout the body. Chronic stress, frustration and emotional pressure constrict Liver Qi, creating stagnation. This manifests as irritability (the Liver cannot drain its emotion), costal tightness (the Liver meridian runs through the ribs) and insomnia due to excess Yang that cannot descend.
Differential diagnosis
Shares: Irritability, lateral headache and a wiry (Xian) pulse.
Sets it apart: Fire adds a bitter taste, red face, thirst, a red tongue with yellow coating and a wiry (Xian), rapid pulse. Here the coating is still thin and white and the pulse is not rapid: the stagnation has not yet generated heat.
Shares: Insomnia, emotional instability and symptoms that worsen before menstruation.
Sets it apart: The deficiency presents with blurred vision, dizziness on standing, brittle nails, a pale tongue and a thin pulse. This patient has red tongue edges and a wiry (Xian) pulse: signs of excess, not vacuity.
Shares: Distension, sighing and symptoms that fluctuate with mood.
Sets it apart: The disharmony adds alternating stools, fatigue after eating and a pulse that is wiry (Xian) but weak in the right Guan (關) position. Watch for it: it is where this case naturally evolves if the stagnation persists.
Treatment
Principle: Soothe the Liver and move Qi, harmonize Liver and Spleen, and settle the Shen.
| Point | Role | Technique |
|---|---|---|
| LV3 | Liver Yuan-source: the point that returns movement to stagnant Qi. | Perpendicular 0.5-0.8 cun, reducing. |
| LI4 | With LV3 it forms the Four Gates: it opens Qi circulation from top to bottom. | Perpendicular 0.5-1 cun, reducing. Contraindicated in pregnancy. |
| LV14 | Liver Mu point: it acts exactly where the patient localizes the tightness. | Oblique or transverse 0.3-0.5 cun along the rib. Never deep perpendicular: pneumothorax risk. |
| PC6 | Opens the chest, descends rebellious Qi and calms the Shen. | Perpendicular 0.5-1 cun, even technique. |
| GB34 | Gallbladder He-sea and influential point of the sinews: it drains Shao Yang and releases the muscular tension that accompanies stagnation. | Perpendicular 1-1.5 cun, reducing. |
| EX-HN3 | Yintang: settles the Shen and helps falling asleep. | Transverse downward 0.3-0.5 cun. |
Formula: Xiao Yao San. Harmonizes Liver and Spleen, the reference formula for this pattern. If heat appears (bitter mouth, red tongue), switch to Jia Wei Xiao Yao San.
- Frequency
- One or two sessions weekly for four to six weeks, reviewing the plan at the fourth session.
Home care
- Diaphragmatic breathing for five minutes before bed, lengthening the exhale.
- Acupressure on LV3, one minute per side, at the end of the day.
- Walk thirty minutes: Liver Qi moves with the body, not with rest.
- Cut back alcohol and coffee, which aggravate the irritability and insomnia of this pattern.
Progress
- Session 1 · day 0 Costal tightness the patient rates 7 out of 10, over an hour to fall asleep, and she describes her day as a tight rope. Four Gates (LV3 + LI4), LV14 and Yintang. The link between sustained stress and the physical symptom is explained, because understanding it reduces hypervigilance about her own body. She leaves with the tightness at 5 out of 10 and sleeps better that night, but the effect fades by the third day.
- Session 2 · day 4 The improvement lasted two days. The throat lump persists and very frequent sighing appears during the intake. The base is kept and PC6 and GB34 are added to open the chest and Shao Yang. Xiao Yao San is started to sustain the effect between sessions, which is exactly what is failing. Within a week the tightness drops to 3 out of 10 and the throat lump appears only in work meetings.
- Session 3 · day 11 Less irritability and six hours of unbroken sleep, but abdominal distension and loose stools appear: the Liver is invading the Spleen. LI4 is dropped, as it disperses too much in a patient who has already released tension, and ST36 and SP6 are added to support the Center. Stools normalize within five days and the distension resolves without further changes to the treatment.
- Session 4 · day 25 Three weeks without costal tightness. She now recognizes on her own which situations trigger the symptom. Sessions are spaced to one every two weeks, keeping only the breathing work and home acupressure. She remains stable over two further reinforcement sessions.
- Discharge
- Treatment ends once she has gone three weeks without costal tightness, sleeps more than six hours, and can name the trigger before her body does.
- Watch for relapses
- Peaks of work pressure and the premenstrual week are the two moments when this pattern returns. One reinforcement session ahead of a foreseeable peak prevents a full relapse.
Health notice. Educational and study content. It describes concepts of Traditional Chinese Medicine and does not replace diagnosis or treatment by a healthcare professional. Needling, medicinal herbs and invasive techniques must be applied by trained professionals. Safety guide.
