Incorrect performance of Qigong exercise can lead to some somatic or psychological disturbances, just like what appeared during the early phase of over-meditation reported by Otis in 1973. [4] Such syndrome manifested during or after the Qigong exercise may be called "Qigong deviation," which has become a diagnostic term now widely used in China. It has also been included in the Chinese Classification of Mental Disorders (1989.) [5] 

The mental disturbances initiated by Qigong exercise has aroused wide interests and discussion now among Chinese psychiatrists and Qigong researchers. 

The diagnosis of "Qigong deviation syndrome" showed the following criteria: 1) normal behavior before doing Qigong exercise; 2) psychological and physiological reactions appear during or after Qigong exercise; suggestion and autosuggestion may play an important role; 3) the manifestation of Qigong deviation syndrome does not meet the diagnostic criteria of schizophrenia, affective disorder and neuroses. 

The clinically common symptom of Qigong deviation is the uncontrolled flow of "Qi" (energy) in the body. All of the cases has such complaints as "Qi moving and dashing within the body" or "Qi dashing and rushing into the head," often stagnating somewhere and leading to pain, with some strange perception in the lower abdominal area called "Dan Tian" (elixir field.) The incessant movement of the vital energy may give rise to an unusual malaise as well as various physical symptoms such as headache, insomnia, discomfort, abdominal distension and others. Owing to the exercisers' overemphasis upon the experience of "arrival of Qi," many interesting psychic phenomena may be derived from: Qi being "stolen" - for instance, an elderly woman was furious when the instructor removed her Qi to another exerciser. She gave that exerciser a box on the ear and asked him to return her Qi. "Induction" of Qi - once there were two exercisers (patients with chronic physical illness) who were in the same ward. One day, one of them gave a puff inadvertently to the other, the latter soon began to dance elegantly. After a little while he told the other mysteriously: "Oh, this is caused by the communication between my Qi and yours." The psychic problem may arise on account of the attitude of the exerciser to the Zi Fa Gong (spontaneous skill), which manifests itself as fast, strenuous and irregular movement with large motions. Some schools of Qigong (as in the crane-flying Qigong) emphasize that the earlier, the larger and the faster the spontaneous skill emerges, the better results will ensue, therefore the exercisers spare no efforts to seek for the spontaneous skill. [6] In most of the exercisers, sensation of Qi, as well as the spontaneous skill were caused by suggestion and autosuggestion and they are prone to develop psychic disorders. 

The common symptoms in mental disturbance are anxiety, nervousness, depression, etc. Seriously ill patients cannot control their own behavior. Some patients are found to have hallucination or delusion, and some even have the impulse of committing suicide. 

Qigong deviation syndrome is a mental disorder closely related to the cultural background, and also to superstition or witchcraft (Case 2.) 

The mental and physical disturbances caused by Qigong deviation have the characteristics different from other psychotic disorders. Their causes are rather complicated. The author has done some tentative study on their clinical and causative factors. 

Of the patients, 25 psychotic cases were assessed by Brief Psychiatric Rating Scale (total mean score of BPRS: 44.89 ± 9.42), and 50 neurotic cases were assessed by Hamilton Rating Scale (total mean score of HAMA [Hamilton depression]: 16.82 ± 6.90; total mean score of HAMD [Hamilton rating scale for depression]: 16.00 ± 8.30.) There are significant differences between the Qigong deviation group and the control group (mean score of HAMD: 2.58 ± 2.22, t = 11.04, P<0.001; mean score of HAMA: 1.94 ± 1.66, t = 11.83, P<0.001.) 
Case Report
Case 1: Mr. A is a 22-year-old unmarried worker. He began to learn himself from Qigong books the "Wu Qin Xi" (exercise mimicking the gestures of five animals) on November 26, 1984 for the treatment of lumbago. Ten days later, he suddenly had "special cenesthesiopathy" with "Qi" flowing adversely in the head and abdomen. When "Qi" flowed into his head, he felt fullness of head and chest distress. When showing a Qigong gesture, he suffered agony and anxiety, even attempting to commit suicide. Two hours later he was sent to Shanghai Institute of Qigong for help. Guided by a Qigong master he recovered. The next day he became delirious and claimed that he could hear the voice of evil spirits; he prayed to Buddha for help but only lost his self control. During the intervals of the attacks, the patient was normal. But he could not work normally due to insomnia and difficulty in coping with Qigong deviation. 

On January 15, 1985, the patient got upset because he was prevented by his family from doing Qigong exercise. He felt so hopeless that he attempted to commit suicide by bumping his head into a car. He was then sent to a hospital for psychiatric treatment. There were no abnormal findings in his physical and laboratory check-up. There was no history of psychosis in his family either. He was treated timely by ECT. Two days later, his father took him back home. Now he is followed up by a Qigong master and is so far in good health state. 

Case 2: Mr. B is a 44-year-old married painter. He learned on his own the "He Xiang Zhuang" (crane-flying Qigong), another school of Qigong in February 1984, attempting to treat his ailment, the hypertrophy of cervical vertebra. He had no personal psychiatric history, neither his family. Several days after Qigong exercise, he was suddenly agitated with hyperthymia. He claimed that he knew everything in the world, "water is associated with the sea," when he talked about the sea, he would "think of the American continent." 

Three days later, he was diagnosed as schizophrenia-like disorder and was treated in Shanghai Psychiatric Hospital. One month later he had remission. 

Later he turned to learn the "Long Men Five Flow," another school of Qigong. On the third morning he suddenly began to cry and dance, still doing Qigong exercise in bed. He thought that his dead mother would be brought back to life whereas he would become a ghost. He said that he could see Buddha and God, and he believed in religion. He also smelt something unusual. He was again admitted to Shanghai Psychiatric Hospital. 

Mental examination: the patient has emotional instability, with no delusion and hallucination, sometimes posing in a Qigong gesture and has intermittent attacks. EPG: extroversion. MMPI: schizophrenic character. He was given 100 mg CPZ im, bid. A week later, he recovered from his illness and now works as before. 

Attention should be paid to the prevention and treatment of various mental and physical disturbances due to Qigong deviation.

..

In Chinese medicine, the qi, the mind, and the breath are all closely related. In a sense, these are not three separate things but are aspects of a single reality. Numerous Chinese medical classics, such as the Nei Jing (Inner Classic) and Nan Jing (Classic of Difficulties), describe how the qi moves through the body in co-ordination with the breath. It is the lungs' respiration, which diffuses and scatters the ancestral or chest qi to spread and extend to the rest of the body. In addition, consciousness in Chinese medicine is referred to as the spirit brilliance, and the spirit is nothing other than the accumulation of qi in the heart. According to many Asian schools of meditation, the thoughts in the mind come and go with the movement of the breath. Therefore, alterations in respiration correspond to alterations in thinking and vice versa. Further, it is qi, which moves the body in space. Hence, there is likewise a relationship between the movement of the mind, the circulation of qi, and the movement of the body.
Most qigong is a combination of either specific is static posture or physical movement coordinated with specific respiration and specific concentration or visualization.
Therefore, we can say that qigong affects the flow of qi in the body, and specific mental-emotional states are evoked by and correspond to specific directions of qi flow. Thus it is easy to see that erroneous qigong can cause abnormal flows o f qi in the body which then causes an uncomfortable, even pathological mental-emotional state.
In addition, if one disturbs the free flow o f the qi mechanism, for instance, by absorbing more qi than the body can freely diffuse and circulate or by accumulating and concentrating the qi in a certain area of the body, this may easily lead to qi stagnation. If this qi stagnation endures, depression may transform fire, and fire flaming upward may harass the heart spirit. Depressive heat may also damage and consume yin fluids, thus giving rise to ascendant hyperactivity of yang, vacuity heat, and/or internal stirring of wind.
On another level, if one is too physically active, activity which is yang may also damage and consume yin fluids leading to yang hyperactivity and evil heat. While too much sitting and inactivity, as in Zen meditation, which is yin, may aggravate liver depression and even cause or aggravate both phlegm dampness and blood stasis. This is even more likely if such still sitting meditation is accompanied by unfulfilled desires, such as wanting to become a Buddha or an Immortal, or if there are excessive worries and anxieties. Especially if one leads the qi in the body upward or concentrates their mind on a point in the upper body, one can lead ministerial fire to counterflow upward. When this disease mechanism causes symptoms of heat harassing upward, it is sometimes referred to as "fire burning the Shaolin monastery." (The Shaolin monastery is the traditional home of Chan or Zen Buddhism, while shao lin literally means "little forest.)

The Symptoms of Qigong Disease
The Chinese medical literature describes three main patterns of qigong disease. These are:

1. Qi stagnation & blood stasis pattern
The main symptoms o f this pattern, of qigong disease are emotional instability, crying and laughing without constancy, paranoia, tension, visual hallucinations, delusional thoughts, chest and ribside fullness and oppression, headache, generalized body pain, a dark, stagnant facial complexion, a dark red tongue or possible static spots or macuIes on the tongue, dark purple, engorged sublingual veins, and a bowstring, choppy pulse.
Emotional impetuosity, difficulty staying still, emotional instability, crying and laughing without constancy, etc. are all symptoms indicating that the qi mechanism is disturbed and chaotic and has lost its control. The qi is commander of the blood, while the blood is the q mother of the qi. When the qi moves, the blood moves. Likewise, if the qi becomes chaotic, the blood becomes disquieted. Hence qi and blood lose their regulation and are unable to control themselves (i.e., one is unable to control oneself).
Qi and blood depression and stagnation may obstruct the heart orifices, resulting in harassment of the heart spirit. Therefore, one may see emotional instability, crying and laughing without constancy, paranoia, tension, visual hallucinations, and delusional thoughts. Static blood obstructing and stagnating may cause qi stagnation of chest yang. In that case, one may see chest and rib-side fullness and oppression. Qi stagnation and blood stasis result in the channels and network vessels not being freeflowing. Hence there is headache, generalized body pain, a dark, stagnant facial complexion, a dark red tongue with possible static spots or macuIes, and a bowstring, choppy pulse.

2. Phlegm fire harassing above pattern
The main symptoms of this pattern of qigong disease are emotional tension and agitation, impulsive movement, breaking things, mania, difficulty controlling oneself, profuse phlegm, chest oppression, a bitter taste in the mouth and bad breath, headache, red eyes, reddish urine, bound stools, a red tongue with thick/ slimy, yellow fur, and a bowstring, slippery, rapid pulse.
If there is habitual bodily yang exuberance (as there often is in young males) or addiction to alcohol and/or tobacco, or excessive eating of fatty, greasy, thick-flavored foods, phlegm dampness may congest and become exuberant. In that case, when one tries to practice qigong, one cannot obtain stillness but the qi mechanism becomes disturbed and chaotic instead. Then phlegm and fire become mixed and internally harass the heart spirit. This then causes emotional tension and agitation, impulsive movement, breaking and damaging things, and manic, chaotic behavior.
lf the qi does not gather in the channels, it is difficult for it to control itself. This then leads to spontaneous sensations of qi discharging chaotically around the body and inability to control oneself. Phlegm turbidity internally obstructing with devitalization of chest yang results in
profuse phlegm and chest oppression, while phlegm fire ascending to harass the clear orifices results in the bitter taste in the mouth, bad breath, headache, and red eyes. The reddish urine, bound stools, red tongue with thick, slimy, yellow fur, and the bowstring, slippery, rapid pulse are all signs of phlegm fire and congested heat.
 

What to do About Qigong Disease
At the very first sign o f qigong disease, the practitioner should stop doing qigong or their practice should be immediately monitored, assessed, and modified by a competent teacher. If symptoms persist, both acupuncture and Chinese herbal medicine can be used to treat any of the above three patterns. Therefore, practitioners with qigong-induced symptoms which do not spontaneously go away when they stop practicing may want to see their local acupuncturist or professional practitioner of Chinese medicine. However, one of the foundations of Chinese medicine is to treat disease before it arises, and the best way to prevent qigong disease is to insure that the type of qigong you are practicing is right for you and that you are doing it correctly. When the right person practices the right kind of qigong in the right manner, then qigong can be a wonderful practice. When practiced wrongly, it can cause mental-emotional disease, hypertension, and heart disease and may lead to stroke. It's good to remember that, in Chinese medicine, health is seen as a matter of balance, and too much qi is just as unhealthy as too little.

BOB FLAWS is the single most prolific writer on Chinese medicine in English. Author, translator, and editor of over 100 books and scores of articles in both professional journals and general magazines, Bob regularly teaches around the country and around the world. Some of his other credits include being a founder, past president, and life-time Fellow of the Acupuncture Association of Colorado, a Fellow and past Governor of the National Academy of Acupuncture & Oriental medicine, past editor of the National Academy's journal, a Fellow of the Register of Chinese Herbal Medicine (UK), a founder of the Council of Oriental Medical Publishers, and the founder, publisher, and editor in chief of Blue Poppy Press, Inc. Bob has been in private practice in Boulder, CO since 1979 where he specializes in gynecology, pediatrics, and complex internal diseases.
 

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). 
 

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 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.
 

•  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 __ ). 

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.