Treating Insomnia with Chinese Medicine 1839972300, 9781839972300

Table of contents :
Treating Insomnia with Chinese Medicine
Cover
Of related interest
Title page
Copyright
Contents
Foreword by Jane Lyttleton
Introduction
Part A: Integrative Knowledge on Insomnia
1. Sleep and Its Mechanism
2. The Characteristics of Insomnia
3. The Pathology of Insomnia
4. The Treatment of Insomnia
Part B: Clinical Experience Synthesis
5. General Considerations in the Treatment of Insomnia with Chinese Medicine
6. Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine
7. Atypical Patterns of Insomnia
8. Classical Formulas
9. Disease-Based Treatment with Chinese Herbal Medicine
10. Treatment Adaptation According to the Person, the Season and the Location
11. Treatment According to Insomnia Subtype
12. Managing Comorbidities
13. Cooking, Intake Methods and Treatment Duration
14. Shen-Calming Herbs
15. Herb Combinations
16. Clinical Tips on the Use of Herbs
17. Other Herbal Treatments
18. Body Acupuncture Treatment
19. Scalp Acupuncture and Ear Acupuncture
20. Other Acupuncture-Related Therapies
21. Tuina Massage
22. Psychology and Music Therapy
23. Integrative Chinese Medicine
24. Yangsheng and Self-Treatment
25. Methods
Bibliography
Subject Index
Author Index

Citation preview

Treating Insomnia with Chinese Medicine

of related interest Acupuncture for Headaches, Eyes and ENT Pathologies Hamid Montakab ISBN 978 0 85701 404 7 eISBN 978 0 85701 405 4

Treating Emotional Trauma with Chinese Medicine Integrated Diagnostic and Treatment Strategies

CT Holman, M.S., L.Ac. ISBN 978 1 84819 318 5 eISBN 978 0 85701 271 5

Treating Psoriasis with Chinese Herbal Medicine (Revised Edition) A Practical Handbook

Sabine Schmitz Foreword by Steve Clavey ISBN 978 1 78775 349 5 eISBN 978 1 78775 350 1

Treating Acne and Rosacea with Chinese Herbal Medicine Sabine Schmitz Foreword by Dan Bensky ISBN 978 1 78775 227 6 eISBN 978 1 78775 228 3

TREATING INSOMNIA with CHINESE MEDICINE A Synthesis of Clinical Experience

YOANN BIRLING Foreword by Jane Lyttleton

First published in Great Britain in 2022 by Singing Dragon An imprint of Jessica Kingsley Publishers An imprint of Hodder & Stoughton Ltd An Hachette Company 1 Copyright © Yoann Birling 2022 Foreword Copyright © Jane Lyttleton 2022 The right of Yoann Birling to be identified as the Author of the Work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988. Front cover image source: Shutterstock® and Deposit Photos. The cover image is for illustrative purposes only, and any person featuring is a model. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means without the prior written permission of the publisher, nor be otherwise circulated in any form of binding or cover other than that in which it is published and without a similar condition being imposed on the subsequent purchaser. A CIP catalogue record for this title is available from the British Library and the Library of Congress ISBN 978 1 83997 230 0 eISBN 978 1 83997 231 7 Printed and bound in Great Britain by CPI Group Jessica Kingsley Publishers’ policy is to use papers that are natural, renewable and recyclable products and made from wood grown in sustainable forests. The logging and manufacturing processes are expected to conform to the environmental regulations of the country of origin. Jessica Kingsley Publishers Carmelite House 50 Victoria Embankment London EC4Y 0DZ www.singingdragon.com

Contents

Foreword by Jane Lyttleton . . . . . . . . . . . . . . . . . . . . . . 7 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Part A: Integrative Knowledge on Insomnia 1. Sleep and Its Mechanism . . . . . . . . . . . . . . . . . . . . . . 17 2. The Characteristics of Insomnia . . . . . . . . . . . . . . . . . . 25 3. The Pathology of Insomnia . . . . . . . . . . . . . . . . . . . . . 33 4. The Treatment of Insomnia . . . . . . . . . . . . . . . . . . . . 45

Part B: Clinical Experience Synthesis 5. General Considerations in the Treatment of Insomnia with Chinese Medicine . . . . . . . . . . . . . . . . . . . . . . . 57 6. Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 7. Atypical Patterns of Insomnia . . . . . . . . . . . . . . . . . . . 104 8. Classical Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . 119 9. Disease-Based Treatment with Chinese Herbal Medicine . . . 142 10. Treatment Adaptation According to the Person, the Season and the Location . . . . . . . . . . . . . . . . . . . . 151 11. Treatment According to Insomnia Subtype . . . . . . . . . . . 163

12. Managing Comorbidities . . . . . . . . . . . . . . . . . . . . . . 173 13. Cooking, Intake Methods and Treatment Duration . . . . . . 183 14. Shen-Calming Herbs . . . . . . . . . . . . . . . . . . . . . . . . . 186 15. Herb Combinations . . . . . . . . . . . . . . . . . . . . . . . . . 194 16. Clinical Tips on the Use of Herbs . . . . . . . . . . . . . . . . . 200 17. Other Herbal Treatments . . . . . . . . . . . . . . . . . . . . . . 202 18. Body Acupuncture Treatment . . . . . . . . . . . . . . . . . . . 206 19. Scalp Acupuncture and Ear Acupuncture . . . . . . . . . . . . . 220 20. Other Acupuncture-Related Therapies . . . . . . . . . . . . . . 222 21. Tuina Massage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 22. Psychology and Music Therapy . . . . . . . . . . . . . . . . . . 234 23. Integrative Chinese Medicine . . . . . . . . . . . . . . . . . . . 238 24. Yangsheng and Self-Treatment . . . . . . . . . . . . . . . . . . . 240 25. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

Foreword When Yoann asked me to write the foreword to this book he could not have known that sleep is one of my favourite topics (and a favourite pastime). Sleep is also an intriguing mystery of human behaviour, that peculiar state akin to coma, death or anaesthesia about which we still know so little. So needless to say, I was delighted by the request. I, like so many parents of babies who don’t sleep, developed an enduring obsession with sleep some decades ago. We, the legion of exhausted parents kept awake during the wee hours of the night, have insight into the effects of sleep deprivation. It is a kind of torture not confined to the pages of spy novels. Sleep deprivation however is not the same as insomnia. But after month or years of interrupted sleep many parents do lose the capacity to sleep well. As do people who work shift work for an extended period of time. The same can apply to people who experience damaging stress, illness, mood disorders or hormone disruptions. In fact, we might think that modern city life is creating for all of us a nightmare scenario when it comes to healthy sleep conditions (even without a baby). We are seemingly always switched on, constantly bathed in the blue light from the screens of displays and devices, and have artificial lighting illuminating the city and the sky all night. But sleep historian Professor Roger Ekirch claims that at ‘no time in history have conditions from human slumber been better than today. Compared with 99 percent of our ancient ancestors, we have better beds, better blankets, better houses, and fewer late-night pests.’1 So I wonder, as did Yoann, what is it that brings so many patients to a Chinese medicine clinic seeking help for insomnia? Humankind has long been intrigued by the phenomenon of sleep. 1

R. Ekirch in Thompson, D. (2022) Can Medieval Sleeping Habits Fix America’s Insomnia? Accessed on 14/04/2022 at https://www.theatlantic.com/ideas/archive/2022/01/ medieval-sleeping-habits-insomnia-segmented-biphasic/621372

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Treating Insomnia with Chinese Medicine

There have been many books written about sleep – from popular ones like Ariana Huffington’s (of the famous eponymous Posts), and bestselling ones like Matthew Walker’s Why We Sleep, to historical treatises and scientific books covering sleep medicine reviews. A quick internet search for books on sleep gives more than 50 current titles – I have read quite a few of them. But this book on sleep may well turn out to be my best pick due to a number of reasons: • it looks at sleep from a traditional Chinese medicine (TCM) perspective (another favourite subject) • it explores some of the mysteries of why we sleep, and what is going on when we can’t • it tells stories about real people and real sleep problems as described by hundreds of TCM doctors in China • it creates an easy to understand synthesis that analyses and summarizes what our TCM forbears have thought important when treating insomnia • it explores solutions to various pathologies that cause debilitating chronic insomnia. Most TCM doctors will read this book to learn more about techniques they can use to make them more effective in the clinic. But what makes this book different is the author’s interest in finding and creating clinical guidelines by searching through literally hundreds of case histories. Yoann analyses 560 clinical experience reports that he found in the Chinese academic literature to generate a clinical experience synthesis (CES), the result of which is a large part of the book you hold in your hands (or see on your screen). He claims (and no one can argue his point) that the strength of this book is in the pooling of clinical experience from many different sources. Yoann’s academic training gives him the tools to analyse this large pool of clinical experience in such a way as to create useful hierarchies that can guide clinicians to make the best treatment decisions. At the outset this book offers a physiological description of the parts of the nervous system responsible for sleep and wakefulness – located in the back of the neck, base of the head and top of the spine – the dumai of course. And just so you get the point of CES straight away, we are told that dumai is the most commonly used meridian for insomnia treatment. That may be news to a number of acupuncturists I know.

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Foreword

This sort of synthesis also shows that the most common pathological mechanism of insomnia (out of eight described) is liver qi stagnation, which may also be a little unexpected for some of us. While an unstable shen is known to be the basis of insomnia, this finding of Yoann’s tells us that stress is a major contributor to disorders seen in patients in China just as it is in the West. Yoann’s CES is illustrated by word clouds. You will have seen these on websites and blogs, but this may be the first time you will have seen them in a TCM text. Such visual cues help the reader get an instant appreciation of how to view a hierarchy of symptoms, herbs or formulas from the most common incidence to the least common incidence among the case reports he examined. TCM herbalists will enjoy the depth of analysis of herbal formulas (including those from the classics), and acupuncturists will be fascinated to see which points the authors of the Chinese case reports liked to use the most. In addition to covering well-known TCM patterns, Yoann includes the impact of gender, age, personality, climate, the 24-hour clock and comorbidities on insomnia and its diagnostic patterns. And in addition to the more common techniques used by TCM doctors, this text includes other remedies such as herbal foot baths and pillows, herbal pastes for the navel, soles or palms, and food therapy. Tuina, acupressure, hypnosis and cognitive-behavioural therapy are also discussed as treatment options. Most students and doctors of TCM love to hear ‘clinical pearls’ – these are priceless little morsels that inform and add nuance to what the college textbooks tell us. Clinical pearls are the TCM equivalents of the secret path instructions that are part of many spiritual traditions. They come directly from the experience and wisdom of expert and knowledgeable masters of the art of TCM. It must have been a joy for Yoann to uncover and collect these sometimes-surprising pearls in his hours spent reading the reports and equally a joy for his reader to share in these. Clinical case studies and the recording of these have long been a foundation of TCM collected wisdom. There has been increasing pressure on doctors practising Chinese medicine to provide evidence of the efficacy of their treatments, in randomized clinical trials. While audits of case studies such as Yoann presents here are not at the top of the evidence-base pyramid (they come below case-controlled studies, randomized controlled trials and meta-analyses), they are not at the bottom

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either. And in a practice of medicine that values an individualized approach, expertise gained by years of practice, a subtle understanding and close attention to complex and detailed observations and nuances of response to treatment (and hence is not easily suited to randomized and blinded clinical trials), such audits are an important and esteemed way of collecting real world evidence. It is always exciting to see another book about Chinese medicine published in English – and one which doesn’t shy away from a rigorous academic and analytical approach to collected data. This book also provides a thorough and up-to-date understanding of Western scientific knowledge, physiology and pathology relating to insomnia. As our profession gains maturity and acceptance in the Western world, it is books like this that help to pave that path. This is a text that will delight and inspire – simply because it is so thorough and so different. I don’t think it will put you to sleep – you will have to try one of the many remedies suggested herein for that. Jane Lyttleton, doctor, author and teacher of Chinese medicine

10

Introduction For Chinese medicine clinicians, the source of knowledge we value the most is also the hardest to obtain. Clinical experience. I can still remember the hours spent in the library at Beijing University of Chinese Medicine reading clinical cases from ancient and modern physicians. The evenings and weekends spent following experienced physicians in the clinic, sometimes until 10 p.m., longing for clinical pearls that would help me become a better clinician. As a postgraduate, I started to shift my attention to academic literature. I found hidden behind the randomized controlled trial, the laboratory experiments and the epidemiological studies literally a forest of clinical experience reports (CERs) – articles written by clinicians (sometimes their students) about the use of a technique, a formula or the treatment of a disease. These CERs were not only a blessing for hungry learners but also so easily accessible. The skills and tools acquired during my doctoral studies at Western Sydney University allowed me to design a research strategy to collect, select and synthesize the information from that huge pool of clinical knowledge. After two years of long and strenuous labour and consultation with experts, the clinical experience synthesis, a systematic synthesis of clinical experience on a specific topic, was born. This book is the first clinical experience synthesis. It aims to answer the question ‘How should we treat insomnia with Chinese medicine?’ Its audience is students and clinicians who are using or willing to use Chinese medicine to treat insomnia. I strongly believe that any clinician, regardless of age, experience and school, will find something valuable in this work. Part A (Chapters 1 to 4) presents the current knowledge about sleep and insomnia in biomedicine and psychology. The first chapter in Part B, Chapter 5, is an overview of the treatment of insomnia with

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Treating Insomnia with Chinese Medicine

Chinese medicine. Chapters 6 to 17 present different aspects of C ­ hinese herbal medicine treatment of insomnia, with a focus on herbal decoctions and granules. Chapters 18 to 20 present acupuncture and related therapies for insomnia. Chapter 21 presents massage treatments for insomnia. Chapters 22 to 24 present Chinese medicine therapies that are usually not presented in textbooks such as psychotherapy, yangsheng and integrative strategies. Finally, Chapter 25 presents the methodology used to collect the knowledge presented in this work. People who are not familiar with the treatment of insomnia with Chinese medicine may want to start with Chapter 6 and Chapter 18, which provide the global strategy to treat insomnia with Chinese herbal medicine and acupuncture. The content of these chapters is similar to that found in textbooks and provides direct guidance. More experienced clinicians may find Chapters 8, 10, 11 and 12 more valuable as they propose discussions on subjects that are usually not debated elsewhere. I added an introduction and a discussion at the beginning and end of each chapter, respectively. These sections do not represent the content of the CERs but rather help the reader to navigate through the different chapters of this book. Compared with existing textbooks and guidelines on the subject, the main strength of this work is that it systematically (without bias of school or approach) collects knowledge in a transparent manner that can be assessed or repeated. Compared with books and individual CERs, this book provides pooled clinical experience from hundreds of clinicians, showing trends and common knowledge rather than personal opinion. In this book, patterns are presented with more flexibility and links than textbooks, which usually provide several patterns as individual blocks with associated signs and symptoms (SSs), herbs and acupuncture points. In this book, we show causal links between these patterns and present a hierarchy of formulas, SSs, herbs and acupoints. This is achieved with the sensibility (sen) value, which represents how widely the SS, herb or acupoint is cited, and the specificity (spe) value, which represents the strength of the association between the SS, herb or acupoint, and the associated pattern. In this book, I describe also therapies that are not always present in textbooks and guidelines, despite being used in the clinic. These therapies include scalp acupuncture, cupping, herbal paste, herbal patches, food therapy, etc. Psychotherapy techniques (those used by Chinese medicine clinicians), yangsheng recommendations and integrative

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Introduction

approaches are also rarely described elsewhere. The treatment of insomnia according to the main complaint and insomnia duration are rarely discussed thoroughly elsewhere. The specific methods of treatment adaptation according to the person, the season and the location are described here, whereas only global principles are available in current textbooks. One of the main strengths of this book is to propose clinical tips. These notes are similar to the tips our mentors give us after a hard day of clinical work. They show highly relevant clinical knowledge on topics such as how to adjust the dose, how to prevent and treat adverse reactions, diagnostic tips, specific acupuncture techniques, etc. This knowledge is rarely available elsewhere. For each of these clinical tips, I provide the citation number (the number of CERs in which this idea was proposed), which allows the reader to assess how consensual the idea is. I would like to acknowledge the support and help of my dear fiancée, Mingxian Jia, who has not only conducted some of the main processes (such as article screening) of the study but also used her valuable time to discuss how to resolve the countless issues that arose down the path and provided unconditional support to her focused partner. Thanks to my doctoral supervisors, Xiaoshu Zhu, Alan Bensoussan and Catrina Tannous, who provided their time, expertise and support on each step of the process, with incredible patience and devotion. Thanks to my beloved mother, Christine Buy, and my sincere friends Emily Yang, Jordan Bencherif, Zhichao Yu, Christine Murray, Andrew Wong and all the others who provided valuable insights on how to improve this method to make it benefit more people.

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Part A

Integrative Knowledge on Insomnia

Chapter 1

Sleep and Its Mechanism 1. The ascending reticular arousal system and wakefulness Sleep is not an active process but the inhibition of the active process of wakefulness. In order to understand what is sleep and how sleep works, one needs to understand first what is wakefulness and how it works. Deep inside our brain stem (the part of the central nervous system between the brain and the spinal cord) lies a system called the ascending reticular arousal system (ARAS). As its name states, this is a neural system composed of a network (reticular) of neurons enmeshed with each other and with the local ascending and descending fibres; its action is directed upward (ascending) and irradiates as far as the cerebral cortex; finally, it has an exciting action. This system is crucial as it maintains wakefulness, consciousness and alertness by constant firing to the cerebral cortex.1 Putting it simply, it keeps us alive. The ARAS, which is located at the crossroads of the central nervous system, receives descending messages from the brain to the body (commands to activate muscles and regulate organ functions) and ascending messages from the body to the brain (sensory messages from the outside world or from internal organs). When ‘things are going on’, motor and sensory messages stimulate the ARAS, which in turn excites the cerebral cortex, keeping us awake, conscious and alert. We can think of the ARAS as a switch that keeps the light on in a room (the brain). It is crucial to understand this point, as factors influencing wakefulness ultimately influence sleep and therefore the symptoms of insomnia. Any sensory stimuli, no matter if external (e.g. noise) or internal (e.g. pain), can affect sleep. Closing the eyes allows us to reduce considerably 1

Brown, R.E., Basheer, R., McKenna, J.T., Strecker, R.E. and McCarley, R.W. (2012) Control of sleep and wakefulness. Physiological Reviews 92(3): 1087–1187; Jones, B.E. (2008) Modulation of cortical activation and behavioral arousal by cholinergic and orexinergic systems. Annals of the New York Academy of Sciences 1129(1): 26–34.

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the input of information passing through the brain stem and therefore decreases the stimulation of the ARAS. Moving implies generating motor input from the brain to the muscles, which stimulates the ARAS as well. In Chinese medicine, the dumai has a key role in controlling the yang and nurturing the brain. From its position and function, the dumai shares many similarities with the ARAS. We will see in Chapter 18 that the dumai is the most commonly used meridian for insomnia. The balance of the yang is also crucial in the maintaining of a healthy sleep–wake schedule. A damage to the brain stem can impair the ARAS, blocking the stimulation of the brain and leading directly to death. Sleep is very similar to death and coma in the sense that the active process of wakefulness is inhibited, although in the case of sleep, wakefulness is only temporarily inhibited and recovers spontaneously. In Chinese medicine, wakefulness, consciousness and alertness, which are related to the cerebral cortex in biomedicine, are a manifestation of the shen or spirit which is controlled by the heart. An excess of wakefulness and alertness, which is called ‘agitation (fanzao)’, is related to excessive heart fire/heat. Wakefulness and consciousness are also related to the concept of ‘clear orifice (qingqiao)’. When the clear orifice is blocked, consciousness is impaired (e.g. in case of severe infection, stroke or coma). Some substances such as caffeine and brain conditions such as epilepsy or stroke have a direct effect on the cerebral cortex and therefore affect the regulation of wakefulness and sleep directly. In Chinese medicine, we can consider that these substances and conditions affect the heart and its regulation of the shen.

2. The definition, structure and function of sleep Sleep can be defined as a naturally recurring biopsychological state characterized by altered consciousness, reduced sensory and motor activities, and reduced interactions with surroundings. It is a complex biological process involving different parts of the brain such as the hypothalamus, the brain stem, the thalamus, the pineal gland and the basal forebrain.2 Sleep is influenced by behaviour, affect and external

2 National Institute of Neurological Disorders and Stroke (2019) Brain basics: Understanding sleep. Accessed on 22/11/2021 at www.ninds.nih.gov/Disorders/ Patient-Caregiver-Education/Understanding-Sleep

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Sleep and Its Mechanism

factors such as light3 and has an influence on almost every type of tissue and system in the body.4 The main characteristics of sleep are automaticity and plasticity.5 Automaticity refers to the fact that sleep is automatically triggered by processes independent of consciousness and decision.6 These processes, the homeostatic drive and the circadian drive, will be described below. Plasticity refers to the fact that the timing, length and structure of sleep is adapted to the needs of the person and the surrounding environment.7 For example, in mammals, sleep is not only influenced by sleep homeostasis, but also by hunger drive,8 the presence of predators or predator cues,9 the motivation to mate10 and long flight.11 Sleep is not a unique state. There are five different stages of sleep: rapid eye movement (REM) sleep and non-rapid eye movement (NREM) stage 1, stage 2, stage 3 and stage 412 (Figure 1.1). REM sleep is characterized by low-amplitude high-frequency activity, which is a feature of wakefulness, rapid eye movements and a complete loss of muscle tone.13 It means that the brain is awake yet disconnected from the rest of the 3 4 5 6 7 8 9

10 11

12 13

Espie, C.A. (2002) Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology 53(1): 215–243. National Institute of Neurological Disorders and Stroke (2019) Brain basics: Understanding sleep. Accessed on 22/11/2021 at www.ninds.nih.gov/Disorders/ Patient-Caregiver-Education/Understanding-Sleep Espie, C.A. (2002) Insomnia: Conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology 53(1): 215–243. Eban-Rothschild, A., Giardino, W.J. and de Lecea, L. (2017) To sleep or not to sleep: Neuronal and ecological insights. Current Opinion in Neurobiology 44: 132–138. Eban-Rothschild, A., Giardino, W.J. and de Lecea, L. (2017) To sleep or not to sleep: Neuronal and ecological insights. Current Opinion in Neurobiology 44: 132–138. Danguir, J. and Nicolaidis, S. (1979) Dependence of sleep on nutrients’ availability. Physiology and Behavior 22(4): 735–740; Dewasmes, G., Duchamp, C. and Minaire, Y. (1989) Sleep changes in fasting rats. Physiology and Behavior 46(2): 179–184. Lima, S.L. (2005) Sleeping under the risk of predation. Animal Behaviour 70(4): 723–736; Lesku, J.A., Bark, R.J., Martinez-Gonzalez, D., Rattenborg, N.C., Amlaner, C.J. and Lima, S.L. (2008) Predator-induced plasticity in sleep architecture in wild-caught Norway rats (Rattus norvegicus). Behavioural Brain Research 189(2): 298–305; Domínguez, J. (2003) Sleeping and vigilance in black-tailed godwit. Journal of Ethology 21(1): 57–60. Lesku, J.A., Rattenborg, N.C., Valcu, M., Vyssotski, A.L. et al. (2012) Adaptive sleep loss in polygynous pectoral sandpipers. Science 337(6102): 1654–1658. Rattenborg, N.C., Mandt, B.H., Obermeyer, W.H., Winsauer, P.J. et al. (2004) Migratory sleeplessness in the white-crowned sparrow (Zonotrichia leucophrys gambelii). PLOS Biology 2(7), e212; Rattenborg, N.C., Voirin, B., Cruz, S.M., Tisdale, R. et al. (2016) Evidence that birds sleep in mid-flight. Nature Communications 7: 12468. Iber, C., Ancoli-Israel, S., Chesson, A.L. and Quan, S.F. (2007) The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Vol. 1. Westchester, IL: American Academy of Sleep Medicine. Brown, R.E., Basheer, R., McKenna, J.T., Strecker, R.E. and McCarley, R.W. (2012) Control of sleep and wakefulness. Physiological Reviews 92(3): 1087–1187.

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body. Most of our dreams occur in the REM stage of sleep. In contrast, NREM sleep is characterized by high-amplitude low-frequency EEG and decreased muscle tone.14 In deep sleep (NREM 3 and NREM 4), the sensory threshold is relatively higher and muscle tone relatively lower than during light sleep (NREM 1 and NREM 2).15 Deep sleep occurs mostly during the first half of the night, whereas REM and light sleep occur mostly during the second half of the night (Figure 1.1).

Hypnogram

Brief awakening

Awakening REM Sleep Stage 1 Stage 2 Stage 3 Stage 4 Midnight

0130

0300

0500

0630

Figure 1.1. Different stages during normal sleep

In Chinese medicine, there is no clear differentiation between light and deep stages of sleep. Nonetheless, dreams (which are the markers of REM sleep) are considered as manifestations of the ethereal spirit or hun, which is controlled by the liver. When the liver is impaired, the hun is not concealed properly, which leads to frequent dreams. It is important to understand that experiencing dreams is part of normal REM sleep (which happens several times every night) but remembering dreams (which is what we really mean by ‘frequent dreams’) is a feature of low sleep quality (i.e. waking up too often and for a period long enough to create memory). Rest and sleep share the functions of energy conservation and muscle relaxation. The main difference between them is that during rest the 14 Brown, R.E., Basheer, R., McKenna, J.T., Strecker, R.E. and McCarley, R.W. (2012) Control of sleep and wakefulness. Physiological Reviews 92(3): 1087–1187. 15 Wu, H.-T., Talmon, R. and Lo, Y.-L. (2014) Assess sleep stage by modern signal processing techniques. IEEE Transactions on Biomedical Engineering 62(4): 1159–1168; Hassan, A.R. and Subasi, A. (2017) A decision support system for automated identification of sleep stages from single-channel EEG signals. Knowledge-Based Systems 128: 115–124.

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Sleep and Its Mechanism

brain is fully active, while in sleep (and especially deep sleep) the brain activity is reduced considerably. For this reason, sleep is essential to brain recovery.16 During sleep, essential molecules and fuel substrates of the central nervous system are replenished17 and waste products that accumulate during the waking state are removed.18 Meanwhile, a global downscaling of synapses resulting from waking neuronal activity enables the processing of new information the next day.19 Learning and memory consolidation are also important functions attributed to sleep.20 These functions are mainly related to deep sleep and REM sleep. Studies in animals and humans revealed that neurons activated during the previous waking episodes in relation to specific tasks are reactivated during SWS, which facilitates the consolidation of memory.21 As mentioned previously, the brain is activated during REM sleep. This activation, which is also related to dreams, allows the processes of memory consolidation, especially for procedural memory.22 Mood regulation is another important function of REM sleep. In addition, we know from previous studies on sleep deprivation that sleep maintains and improves the immune system.23 Low sleep efficiency 16 Rattenborg, N.C., de la Iglesia, H.O., Kempenaers, B., Lesku, J.A., Meerlo, P. and Scriba, M.F. (2017) Sleep research goes wild: New methods and approaches to investigate the ecology, evolution and functions of sleep. Philosophical Transactions of the Royal Society B: Biological Sciences 372(1734): 20160251. 17 Benington, J.H. and Heller, H.C. (1995) Restoration of brain energy metabolism as the function of sleep. Progress in Neurobiology 45(4): 347–360; Scharf, M.T., Naidoo, N., Zimmerman, J.E. and Pack, A.I. (2008) The energy hypothesis of sleep revisited. Progress in Neurobiology 86(3): 264–280. 18 Xie, L., Kang, H., Xu, Q., Chen, M.J. et al. (2013) Sleep drives metabolite clearance from the adult brain. Science 342(6156): 373–377. 19 De Vivo, L., Bellesi, M., Marshall, W., Bushong, E.A. et al. (2017) Ultrastructural evidence for synaptic scaling across the wake/sleep cycle. Science 355(6324): 507–510; Diering, G.H., Nirujogi, R.S., Roth, R.H., Worley, P.F., Pandey, A. and Huganir, R.L. (2017) Homer1a drives homeostatic scaling-down of excitatory synapses during sleep. Science 355(6324): 511–515. 20 Stickgold, R. (2005) Sleep-dependent memory consolidation. Nature 437(7063): 1272– 1278; Walker, M.P. and Stickgold, R. (2004) Sleep-dependent learning and memory consolidation. Neuron 44(1): 121–133. 21 Diekelmann, S. and Born, J. (2010) The memory function of sleep. Nature Reviews Neuroscience 11(2): 114–126. 22 Laureys, S., Peigneux, P., Phillips, C., Fuchs, S. et al. (2001) Experience-dependent changes in cerebral functional connectivity during human rapid eye movement sleep. Neuroscience 105(3): 521–525; Stickgold, R., Whidbee, D., Schirmer, B., Patel, V. and Hobson, J.A. (2000) Visual discrimination task improvement: A multi-step process occurring during sleep. Journal of Cognitive Neuroscience 12(2): 246–254. 23 Everson, C.A. (1993) Sustained sleep deprivation impairs host defense. American Journal of Physiology: Regulatory, Integrative and Comparative Physiology 265(5): R1148–R1154; Lange, T., Perras, B., Fehm, H.L. and Born, J. (2003) Sleep enhances the human antibody response to hepatitis A vaccination. Psychosomatic Medicine 65(5): 831–835.

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(i.e. the ratio of time asleep to time in bed) is associated with a significant increase in susceptibility to colds.24 In Chinese medicine, sleep is characterized as a state in which ‘the yang penetrates the yin’. The yin state of sleep, with yin features of calm and passivity and yin functions of collecting and conserving, is opposed to the yang state of wakefulness, which is an active state of consumption. However, there is no consensus on what is collected during sleep: is it yin or yang? From the perspective of brain functions, memory and mood regulation, sleep seems to be conserving and consolidating blood and essence. Yet from the perspective of energy conservation and the immune system, sleep seems to be conserving and consolidating yang and qi. Both aspects are likely to be involved.

3. The mechanism of sleep As mentioned previously, sleep is the inhibition of wakefulness rather than an active process. This inhibition is mainly due to two sleep drives, the homeostatic drive and the circadian drive,25 and maintained by the behavioural process of conditioned de-arousal. The homeostatic drive or sleep–wake homeostasis is the most basic regulation system of sleep and wake. This process is controlled by the ventrolateral preoptic nucleus (VLPO), which is situated in the hypothalamus. During prolonged periods of wakefulness, the depletion of glycogen and the accumulation of adenosine in the forebrain disinhibits the VLPO.26 The neurons of the VLPO then inhibit the ARAS via the action of gamma-butyric acid (GABA) and galanin,27 which promotes sleep. In Chinese medicine, this process can be understood from the perspective of yinyang theory. The rise of yang (i.e. energy consumption) when we are active during the day leads eventually to the rise of yin (i.e. energy conservation) when the energy is consumed completely. The second drive is the circadian rhythm, which is a biological rhythm 24 Cohen, S., Doyle, W.J., Alper, C.M., Janicki-Deverts, D. and Turner, R.B. (2009) Sleep habits and susceptibility to the common cold. Archives of Internal Medicine 169(1): 62–67. 25 Borbély, A.A. (1982) A two process model of sleep regulation. Human Neurobiology 1(3): 195–204; Borbély, A.A., Daan, S., Wirz-Justice, A. and Deboer, T. (2016) The two-process model of sleep regulation: A reappraisal. Journal of Sleep Research 25(2): 131–143. 26 Schwartz, J.R. and Roth, T. (2008) Neurophysiology of sleep and wakefulness: Basic science and clinical implications. Current Neuropharmacology 6(4): 367–378. 27 Saper, C.B., Chou, T.C. and Scammell, T.E. (2001) The sleep switch: Hypothalamic control of sleep and wakefulness. Trends in Neurosciences 24: 726–731.

22

Sleep and Its Mechanism

that regulates biological activities such as heart rate, oxidative stress, cell metabolism, and immune and inflammatory responses on a 24-hour basis. The markers of this 24-hour rhythm are melatonin level (which is higher during night-time), cortisol level (which is higher during daytime) and body temperature (which is higher during daytime).28 The circadian rhythm is controlled by the suprachiasmatic nucleus (SCN), which is located in the hypothalamus. The neurons of the SCN show a 24-hour rhythm pattern in their neural output which arises from self-sustaining molecular feedback loops of clock gene expression.29 The circadian rhythm is primarily regulated by light, which is the most important zeitgeber (German, meaning time-giver). Light travels from the retina to the SCN via the retinohypothalamic tract. In the absence of light, the SCN sends signals to the pineal gland to secrete melatonin, which then acts on the MT-1 and MT-2 receptors of the SCN to synchronize the circadian rhythm.30 The SCN has direct and indirect projections to the VLPO, which in turn inhibits the ARAS and therefore promotes sleep.31 In Chinese medicine, the circadian rhythm is related to the movement of the protective qi (weiqi), which, according to the Huangdi Neijing, makes 25 rounds in the yang during the day and 25 rounds in the yin during the night. The underlying philosophy behind this understanding is the union between humans and their environment (tianren heyi). According to traditional theories, the yang starts to rise after midnight, grows in the morning, is the strongest at noon and declines during the afternoon and evening, following the movement of the sun (which light regulates the circadian cycle in biomedicine). The homeostatic drive is already in place in newborn babies. The circadian drive gradually settles during the first months of life. Every night, 28 Benloucif, S., Guico, M.J., Reid, K.J., Wolfe, L.F., L’hermite-Balériaux, M. and Zee, P.C. (2005) Stability of melatonin and temperature as circadian phase markers and their relation to sleep times in humans. Journal of Biological Rhythms 20(2): 178–188; Adam, E.K., Quinn, M.E., Tavernier, R., McQuillan, M.T., Dahlke, K.A. and Gilbert, K.E. (2017) Diurnal cortisol slopes and mental and physical health outcomes: A systematic review and meta-analysis. Psychoneuroendocrinology 83: 25–41. 29 Jones, J.R., Tackenburg, M.C. and McMahon, D.G. (2015) Manipulating circadian clock neuron firing rate resets molecular circadian rhythms and behavior. Nature Neuroscience 18(3): 373–375. 30 Tordjman, S., Chokron, S., Delorme, R., Charrier, A. et al. (2017) Melatonin: Pharmacology, functions and therapeutic benefits. Current Neuropharmacology 15(3): 434–443; Moore, R.Y. (2007) Suprachiasmatic nucleus in sleep–wake regulation. Sleep Medicine 8(3): 27–33. 31 Moore, R.Y. (2007) Suprachiasmatic nucleus in sleep–wake regulation. Sleep Medicine 8(3): 27–33.

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we experience a de-arousal process (i.e. inhibition of wakefulness) in the sleep environment. As time passes, the neutral stimuli such as the bed, the bedroom or night-time become associated with de-arousal and become sleep stimuli.32 It means that exposure to these stimuli (i.e. seeing the bedroom, feeling the bed) provokes a conditioned de-arousal which facilitates sleep. As in other types of classical conditioning, the strength of the stimulus (i.e. its ability to induce sleep) depends on the number of activities associated with it – the stimulus is stronger when associated with sleep only and weaker when associated with other activities such as watching TV, eating or worrying.33 To summarize, wakefulness is maintained by the constant firing of ARAS neurons to the cerebral cortex. The ARAS is stimulated by any motor or sensory activity that passes through the brain pons. Sleep is induced by the homeostatic drive (i.e. need for sleep) which depends on the time spent awake and the circadian drive (i.e. biological clock), which is mainly regulated by exposure to light. These drives reduce the activity of the ARAS, ultimately reducing cerebral cortex activity. Sleep is facilitated by the process of conditioned de-arousal, which is due to the association between the sleep environment and the biological inhibition of the ARAS. Virtually any factor influencing the ARAS, the homeostatic drive, the circadian drive, the conditioned de-arousal or the cerebral cortex directly can have a positive or negative influence on insomnia.

32 Perlis, M., Shaw, P., Cano, G. and Espie, C. (2011) Models of insomnia. Principles and Practice of Sleep Medicine 5: 850. 33 Perlis, M., Shaw, P., Cano, G. and Espie, C. (2011) Models of insomnia. Principles and Practice of Sleep Medicine 5: 850.

24

Chapter 2

The Characteristics of Insomnia 1. The definition of insomnia The term ‘insomnia’ describes a difficulty to initiate or maintain sleep and can refer to a symptom as well as a disorder. As we have seen previously, many biological, psychological and social factors can influence sleep and therefore provoke insomnia symptoms. Most of us (if not all) have at some time experienced difficulty sleeping. As insomnia symptoms are relatively normal, they do not need to be managed. When these symptoms reach certain levels in terms of frequency, duration and consequences, they are labelled ‘insomnia disorder’ or ‘chronic insomnia’, a condition in which active management is indicated. Insomnia disorder is usually diagnosed using international diagnosis tools such as that in the Diagnostic and Statistical Manual (DSM, developed by the American Psychiatric Association), the International Classification of Sleep Disorders (ICSD, developed by the American Academy of Sleep Medicine) and the International Classification of Diseases (ICD, developed by the World Health Organization). As the three organizations that produce these diagnostic tools have different perspectives and objectives, the diagnostic criteria of insomnia disorder in these three diagnostic tools were different for many years. In the latest versions of these diagnostic tools (the DSM-5, the ICSD-3 and the ICD-11), the three organizations have, surprisingly, reached a consensus (based on the diagnostic criteria of the DSM-5). This shows the significant advances in the understanding of insomnia disorder in the past 30 years. This diagnostic criteria is:1 1

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association.

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1. A self-reported complaint of poor sleep quality including one of the following: – difficulties initiating sleep – difficulties maintaining sleep – waking up earlier than desired. 2. Sleep difficulties occur despite adequate sleep opportunity. 3. Impaired sleep produces clinically significant distress or impairment across personal, vocational, behavioural, social, educational or other areas of functioning. 4. Sleep difficulty occurs three nights per week and is present for three months. 5. The complaint of insomnia is not completely explained by the use of a substance or a medical condition (including other sleep disorders and other psychiatric disorders). Importantly, there is no strict limit in terms of sleep onset latency (the time needed to fall asleep), the number of awakenings during the night or time of awakening in the morning. Instead, there is an emphasis on the ‘difficulty’ – that is, the perceived trouble and struggle to fall asleep or get back to sleep. Non-restorative sleep (not feeling refreshed after waking up in the morning despite enough sleep quantity) can be part of the clinical feature but does not qualify for insomnia disorder as a stand-alone symptom. Frequent dreams are not considered a symptom of insomnia either. If the sleep difficulties can be explained by environmental factors (e.g. excessive noise, light, extreme temperatures), by the use of a substance (especially some medications or alcohol) or another medical condition (e.g. chronic pain, hot flushes), the diagnosis of insomnia is not reached. This does not mean that environmental factors, substances and medical conditions cannot be involved in the pathology of insomnia (see Chapter 3). It shows that the management should focus on the environmental factors, the substance or the other medical condition if the sleep difficulties are directly caused by these (which is rarely the case). As we have seen previously, insomnia symptoms are common in the general population and should not be actively managed if they are not present at least three nights per week for at least three months. If the other criteria are met but the symptoms have been present for less than three months, a diagnosis of ‘short-term insomnia’ can be reached.

26

The Characteristics of Insomnia

In most cases, however, short-term insomnia is self-limiting, whereas long-term insomnia usually lasts for decades. Another important point in the diagnosis of insomnia is that the sleep disturbances should provoke significant distress or social impairment. Sometimes patients are pushed by their family members or friends to consult for insomnia because their sleep ‘is not normal’. As there is no strict definition of what is ‘normal sleep’, insomnia should not be actively managed if there is no subjective or objective negative impact on the patient. The prevalence of insomnia in the general population depends largely on its definition. Insomnia symptoms are experienced by more than 50% of the population but only around 12% of the population meets the diagnostic criteria of insomnia disorder.2 In Chinese medicine, there is no strict definition of insomnia disorder. The disease diagnosis of ‘insomnia (bumei)’ includes difficulty falling asleep, waking up frequently, early-morning awakenings, light sleep and frequent dreams, regardless of the frequency and duration of these symptoms. It is important to distinguish insomnia from sleep deprivation. Sleep deprivation is an objective lack of sleep. For example, if someone who needs seven hours of sleep to feel refreshed has only six hours of sleep, this is sleep deprivation. Sleep deprivation is usually caused by a busy schedule (i.e. no time for sleep) or some conditions such as sleep apnoea, in which sleep is impaired by biological processes. Sleep deprivation can be observed in insomnia patients but is not a typical feature of insomnia. The main features of insomnia are frustration and worries about sleep. The objective sleep of the large majority of people who report trouble sleeping is not shorter than for people who report having a good sleep. Insomnia patients feel tired and believe their cognitive functions (e.g. memory, attention) are impaired, but objective tests on sleepiness (i.e. the propensity to fall asleep) and cognitive functions do not support this claim (or at least they are much less sleepy and cognitively impaired than people with sleep apnoea, for example). 2

Benbir, G., Demir, A., Aksu, M. and Ardic, S. (2015) Prevalence of insomnia and its clinical correlates in a general population in Turkey. Psychiatry and Clinical Neurosciences 69(9): 543–552; Castro, L.S., Poyares, D., Leger, D., Bittencourt, L. and Tufik, S. (2013) Objective prevalence of insomnia in the São Paulo, Brazil epidemiologic sleep study. Annals of Neurology 74(4): 537–546; Uhlig, B.L., Sand, T., Odegård, S.S. and Hagen, K. (2014) Prevalence and associated factors of DSM-V insomnia in Norway: The Nord-Trøndelag Health Study (HUNT 3). Sleep Medicine 15(6): 708–713.

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In Chinese medicine, sleep deprivation is associated with yangqi, blood or essence deficiency. As we will see in Part B of this book, deficiency is not a main feature of insomnia pathology (except for the HeartSpleen Deficiency pattern). Stagnation and heat, which are related to stress reaction and hyperarousal, are much more common in insomnia patients.

2. Different types of insomnia Insomnia can be categorized into subtypes according to the duration of the disease, the complaint and the objectivity of the symptoms. However, we will see that these categorizations are not necessarily accurate or clinically relevant. Primary and secondary insomnia will be discussed in Chapter 3. The distinction between acute and chronic insomnia is not only one of the earliest3 but also the most consistent in insomnia nosology. Both the DSM-54 and the ICSD-35 use a three-month threshold to define chronic insomnia (the term ‘insomnia disorder’ is used in the DSM-5). This distinction is clinically useful as acute insomnia is considered to be mainly caused by biological (e.g. caffeine), psychological (e.g. acute stress) and social (e.g. jet lag) precipitating factors, whereas chronic insomnia is mainly maintained by behavioural and cognitive perpetuating factors.6 However, Espie and colleagues propose that the transition from acute or ‘adjustment’ insomnia to chronic or ‘psychophysiologic’ insomnia occurs when the selective attention of the patient shifts from stressors to insomnia symptoms themselves.7 Quite obviously this shift does not always occur at the three-month timepoint. From a Chinese medicine perspective, there is also a distinction between acute and chronic insomnia, the former being associated with liver qi stagnation while the latter is associated with phlegm and blood

3 4 5 6 7

Sateia, M.J. (2014) International classification of sleep disorders. Chest 146(5): 1387–1394. American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. American Academy of Sleep Medicine (2014) International Classification of Sleep Disorders (3rd edn). Darien, IL: American Academy of Sleep Medicine. Perlis, M.L. (2005) Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer. Espie, C.A., Broomfield, N.M., MacMahon, K.M.A., Macphee, L.M. and Taylor, L.M. (2006) The attention–intention–effort pathway in the development of psychophysiologic insomnia: A theoretical review. Sleep Medicine Reviews 10(4): 215–245.

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The Characteristics of Insomnia

stasis (see Chapter 11). The timepoint at which the transition occurs is not clear either. Insomnia can also be classified according to the type of complaint – that is, difficulty falling asleep, difficulty maintaining sleep, early-morning awakenings and non-restorative sleep.8 A longitudinal study on insomnia subtypes9 found that for most of patients the insomnia symptom subtype changes over a four-month period, bringing into question the relevance of this classification used in cross-sectional studies. This classification is also challenged by the fact most insomnia patients show at least two subtypes at the same time.10 Additionally, a study using polysomnography showed that non-restorative sleep (NRS) can occur independently of other components of insomnia,11 and a five-year follow-up study suggested that NRS has its own longitudinal course and association with mental and medical outcome,12 leading the DSM-5 to exclude NRS from the diagnostic criteria of insomnia disorder. In Chinese medicine, insomnia complaints are associated with different pathological features. We will see in Chapter 11 that difficulty falling asleep is associated with either stagnation of heat/fire, frequent awakenings are associated with blood deficiency, early-morning awakenings are associated with kidney deficiency, and frequent dreams are associated with liver pathology. The use of polysomnography (PSG), a multi-parametric test in which brain waves, oxygen levels, heart rate, breathing, eye movements and leg movements are recorded during one entire night, allowed researchers to explore the objectivity of insomnia in the 1970s. Researchers were 8

Benbir, G., Demir, A., Aksu, M. and Ardic, S. (2015) Prevalence of insomnia and its clinical correlates in a general population in Turkey. Psychiatry and Clinical Neurosciences 69(9): 543–552. 9 Hohagen, F., Kappler, C., Schramm, E., Riemann, D., Weyerer, S. and Berger, M. (1994) Sleep onset insomnia, sleep maintaining insomnia and insomnia with early morning awakening – temporal stability of subtypes in a longitudinal study on general practice attenders. Sleep 17(6): 551–554. 10 Leger, D. and Poursain, B. (2005) An international survey of insomnia: Under-recognition and under-treatment of a polysymptomatic condition. Current Medical Research and Opinion 21(11): 1785–1792; Xiang, Y.T., Ma, X., Cai, Z.J., Li, S.R. et al. (2008) The prevalence of insomnia, its sociodemographic and clinical correlates, and treatment in rural and urban regions of Beijing, China: A general population-based survey. Sleep 31(12): 1655–1662. 11 Roth, T., Zammit, G., Lankford, A., Mayleben, D. et al. (2010) Nonrestorative sleep as a distinct component of insomnia. Sleep 33(4): 449–458. 12 Zhang, J.H., Lam, S.P., Li, S.X., Li, A.M. and Wing, Y.K. (2012) The longitudinal course and impact of non-restorative sleep: A five-year community-based follow-up study. Sleep Medicine 13(6): 570–576.

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puzzled when they realized that many patients who complained of difficulties sleeping did not show objective signs of insomnia. These patients, who maintained that they experienced difficulty sleeping despite showing the opposite, were diagnosed with ‘sleep state misperception’ or ‘paradoxical insomnia’, a condition in which the perception (but not the reality) of sleep is impaired. A large-scale study in Brazil showed that objective insomnia (difficulty falling asleep for at least 30 minutes as measured with PSG) was experienced by only 37% of insomnia complainers and as many as 23% of self-reported good sleepers.13 Nowadays, sleep perception impairment is not considered a separate diagnosis but rather one of the main features of insomnia disorder.14 The misperception of sleep is due to excessive cortical activity during sleep compared with good sleepers.15 In normal time, we know we slept because memory is not created during sleep stages – that is, we do not know what happened during the last few hours. The excessive cortical activity exhibited by insomniacs allows the creation of memory: they ‘remember’ what happened during sleep and therefore believe they did not sleep.

3. Relationship with other sleep disorders Insomnia disorder is the most common of sleep disorders, which include sleep apnoea, hypersomnolence disorder, narcolepsy, circadian rhythm disorders, restless leg syndrome and parasomnias. Sleep apnoea is characterized by disruption of the air flow in the respiratory tract during the night, manifested by loud snoring and breathing pauses. When breath is discontinued, the drop in oxygen level provokes an abrupt stress reaction that leads to awakening. As patients are awakened or taken back to light sleep every time they reach deep sleep (in which the relaxation of respiratory muscles is more pronounced), sleep apnoea leads to sleep deprivation and daytime sleepiness. This is different from insomnia, in which patients are hyperaroused both during the 13 Castro, L.S., Poyares, D., Leger, D., Bittencourt, L. and Tufik, S. (2013) Objective prevalence of insomnia in the São Paulo, Brazil epidemiologic sleep study. Annals of Neurology 74(4): 537–546. 14 Reynolds III, C.F., Kupfer, D.J., Buysse, D.J., Coble, P.A. and Yeager, A. (1991) Subtyping DSM-III-R primary insomnia: A literature review by the DSM-IV work group on sleep disorders. The American Journal of Psychiatry 148(4): 432. 15 Perlis, M.L., Giles, D.E., Mendelson, W.B., Bootzin, R.R. and Wyatt, J.K. (1997) Psychophysiological insomnia: The behavioural model and a neurocognitive perspective. Journal of Sleep Research 6(3): 179–188.

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The Characteristics of Insomnia

day and the night. From a Chinese medicine perspective, sleep apnoea is related to phlegm, dampness, qi deficiency and blood stasis, whereas insomnia is more closely associated with stagnation and heat/fire. Hypersomnolence disorder and narcolepsy are both characterized by excessive sleep during the day. The essential features of the former are an excessive unrefreshing sleep at night (usually more than nine hours) and an ongoing sleepiness during the day with recurrent lapses into sleep. The essential features of the latter are repeated irresistible attacks of refreshing sleep, cataplexy (paralysis) and intrusions of REM sleep elements (e.g. dream-like hallucinations, sleep paralysis). As daytime sleep impairs the homeostatic drive, patients can experience trouble sleeping at night as well. When sleep is excessive during the day and impaired at night, it is important to understand which one caused the other chronologically. In Chinese medicine, hypersomnolence disorder and narcolepsy are related with yangqi deficiency and excessive phlegm-dampness, whereas insomnia is more commonly characterized by qi stagnation and heat/fire. Circadian rhythm sleep disorders – conditions in which there is a mismatch between a socially accepted sleep time and the timing of the circadian rhythm of the patient – can manifest with clinical features similar to insomnia. Delayed circadian rhythm disorder patients have usually trouble initiating sleep, and advanced circadian rhythm disorder patients usually present with early-morning awakenings. However, these symptoms disappear if a sleep cycle corresponding with the endogenous circadian rhythm is adopted. Shift-work-type circadian rhythm disorder occurs only in the circumstances of shift work. Restless leg syndrome is a condition characterized by unpleasant sensations in the legs with an urge to move the legs. The condition usually worsens at night and when resting, which makes it highly susceptible to affecting sleep. Patients who have trouble sleeping should be screened for restless leg syndrome. Parasomnias are characterized by a complaint of unusual behaviour or events (e.g. nightmares, sleepwalking, sleeptalking, sleep terrors) during sleep that may lead to intermittent awakenings and difficulty resuming sleep. In parasomnias, the unusual behaviour or event dominates the clinical picture. Insomnia can be comorbid with these other sleep disorders. It means that both conditions exist independently. For example, one might wake up in the middle of the night because of sleep apnoea or

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Treating Insomnia with Chinese Medicine

parasomnias, then start to be worried about not getting enough sleep or impair sleep conditioning by staying in bed while awake, leading to insomnia disorder. Excessive sleep during the day, such as manifested in hypersomnolence disorder and narcolepsy, can lead to impaired sleep at night, leading to a vicious circle between impaired sleep at night and excessive sleep during the day. From a Chinese medicine perspective, some sleep disorders (e.g. parasomnias, restless leg syndrome) can share pathological mechanisms such as blood deficiency, liver stagnation and liver fire with insomnia.

32

Chapter 3

The Pathology of Insomnia 1. The hyperarousal theory The hyperarousal theory was proposed very early on to explain insomnia. Studies using electromyogram, body temperature measurements, electrocardiogram and skin conductance measurements showed a higher degree of arousal for bad sleepers compared with good sleepers.1 As sleep is by definition a systematic (but temporary) inhibition of cortical activity, it seemed logical to consider insomnia being caused by an excessive cortical activity. Cortical hyperarousal does not only explain why insomnia patients spend more time awake during the night than normal sleepers, it also provides an explanation or the misperception of sleep state by insomniacs. During sleep, the cerebral cortex of insomnia patients is excessively active, therefore they tend to be more sensitive to external stimuli (e.g. noise, light), create long-term memory and process information, which ultimately make them feel they are awake.2 We also know that the hyperarousal is not only present during the night but also during the day.3 From a Chinese medicine perspective, the concept of cortical hyperarousal can be related to excessive heart yang or heart fire disturbing the shen. The most common symptom of heart fire is agitation (fanzao), which corresponds to the elevated wakefulness and awareness associated with cortical hyperarousal. We will see in Chapter 6 that agitation is

1 2 3

Adam, K., Tomeny, M. and Oswald, I. (1986) Physiological and psychological differences between good and poor sleepers. Journal of Psychiatric Research 20(4): 301–316. Perlis, M.L., Giles, D.E., Mendelson, W.B., Bootzin, R.R. and Wyatt, J.K. (1997) Psychophysiological insomnia: The behavioural model and a neurocognitive perspective. Journal of Sleep Research 6(3): 179–188. Riemann, D., Spiegelhalder, K., Feige, B., Voderholzer, U. et al. (2010) The hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Medicine Reviews 14(1): 19–31.

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a common symptom in every type of insomnia except the Heart-Spleen Deficiency type. Cortical hyperarousal can explain the symptoms of insomnia patients but not the reason why they are experiencing these symptoms. Stress reaction and the flip-flop theory allow us a deeper understanding. Stress reaction is a systematic biological response that can be engaged when the body is facing a threat. Resources are shifted from long-term goal systems (e.g. digestive and reproductive systems) toward short-term goal systems (e.g. cardiovascular, respiratory and musculoskeletal systems) in order to prepare for a fight-or-flight behavioural response. Stress reaction is characterized by hypothalamus–pituitary– adrenal axis arousal, autonomic nervous system activation and immune system modifications. As we saw in Chapter 1, wakefulness is maintained by the ARAS (which includes the locus coeruleus, the tuberomamillary nucleus and the raphe), which keeps the cerebral cortex active. Sleep is induced by the stimulation of the VLPO due to the homeostatic drive and the circadian drive. There is a mutual inhibition between the ARAS and the VLPO (Figure 3.1.). During wakefulness, the ARAS is active and inhibits the VLPO, whereas during sleep the VLPO is active and inhibits the ARAS.4 This mutual inhibition is further stabilized by orexin neurons from the lateral hypothalamus.5 This sleep ‘switch’ prevents intermediate states between sleep and wake.6 Autonomic arousal such as the one present in stress reaction stimulates the ARAS. When insomnia patients go to bed, there is both a stimulation of the VLPO due to homeostatic and circadian drives and a stimulation of the ARAS due to autonomic arousal. Neither the VLPO nor the ARAS wins the fight and the patient is left in a state between sleep and wakefulness. Although Chinese medicine does not traditionally recognize stress reaction, it considers that emotions are associated with the regulation of qi movements. Excessive emotions are associated with liver qi stagnation and liver fire. It is not hard to find correspondence between the 4

5 6

Saper, C.B., Chou, T.C. and Scammell, T.E. (2001) The sleep switch: Hypothalamic control of sleep and wakefulness. Trends in Neurosciences 24: 726–731; Kilduff, T.S. and Peyron, C. (2000) The hypocretin/orexin ligand–receptor system: Implications for sleep and sleep disorders. Trends in Neurosciences 23(8): 359–365. Kilduff, T.S. and Peyron, C. (2000) The hypocretin/orexin ligand–receptor system: Implications for sleep and sleep disorders. Trends in Neurosciences 23(8): 359–365. Saper, C.B., Chou, T.C. and Scammell, T.E. (2001) The sleep switch: Hypothalamic control of sleep and wakefulness. Trends in Neurosciences 24: 726–731.

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The Pathology of Insomnia

manifestation of stress reaction and the signs of liver qi stagnation and liver fire, such as thoracic pressure, palpitations, agitation and stomach distension. As we will see in Chapter 6, liver qi stagnation and liver fire are core mechanisms of insomnia. These mechanisms can lead to heart fire and shen disturbance. A

ORX LC TMN Raphe VLPO eVLPO

Awake

On

ORX

B Sleep

VLPO eVLPO

LC TMN Raphe Off

Figure 3.1. Schematic diagram of the flip-flop model

Acute stress reaction due to life events such as work stress, moving or marriage can explain the cortical arousal observed in acute insomnia patients. However, most chronic insomnia patients do not experience stress-inducing life events. In order to understand how the cortical and subcortical hyperarousals are maintained in chronic patients, we need to shift our attention from biology to psychology.

2. Psychological factors We saw previously that the sleep behaviour is reinforced by sleep conditioning. Humans are conditioned to sleep in a certain environment (i.e. in a bed, in a bedroom) at a certain time (i.e. at night). This explains why we can have trouble sleeping when we sleep in a new environment – when travelling, for example. As insomniacs tend to spend

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Treating Insomnia with Chinese Medicine

a substantial time awake in bed, the sleep environment (special and temporal) becomes associated with wakefulness, worry and rumination. Many insomnia patients report having no trouble falling asleep in the living room in front of the television but become fully awake when reaching the bedroom. The theory of sleep conditioning was hypothesized by Bootzin in 1972 on the basis of his work on sleep conditioning therapy (i.e. using behavioural techniques to re-instil sleep conditioning in insomnia patients).7 Later, Spielman observed that insomnia patients tend to have a coping mechanism to ‘make up’ for lost sleep, such as advancing bedtime, staying in bed for longer in the morning and napping during the day.8 He proposed the idea of ‘perpetuating factors’ of insomnia – that is, behavioural factors aimed at coping with insomnia symptoms (e.g. extending the time spent in bed) – that ultimately maintain insomnia by impairing sleep conditioning, reducing sleep pressure and disturbing the circadian cycle. Despite years of research in the field of sleep medicine, there is no reliable evidence showing an extension of the time in bed and increased napping behaviours in insomnia patients. By definition, insomnia patients spend more time awake in bed than good sleepers; however, this could simply be a symptom rather than a cause of insomnia. The best evidence for the behavioural perpetuation theory is the clinical efficacy of behavioural therapy aimed at correcting these behaviours. It is unclear if insomnia patients adopt maladaptive behaviours, but we know that the perception and beliefs about sleep change when people develop insomnia. Good sleepers tend to have little expectation and concern about sleep. When people start to experience insomnia (usually due to an acute stress reaction), they develop maladaptive beliefs that maintain the stress reaction and therefore the cortical hyperarousal. These maladaptive beliefs include:9 • misattribution about the causes of insomnia (e.g. ‘there must be something wrong with my body’) 7 8 9

Bootzin, R.R. (1972) Stimulus control treatment for insomnia. Proceedings of the American Psychological Association 7: 395–396. Spielman, A.J., Caruso, L.S. and Glovinsky, P.B. (1987) A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America 10(4): 541–553. Harvey, A.G. (2002) A cognitive model of insomnia. Behaviour Research and Therapy 40(8): 869–893; Morin, C.M., Stone, J., Trinkle, D., Mercer, J. and Remsberg, S. (1993) Dysfunctional beliefs and attitudes about sleep among older adults with and without insomnia complaints. Psychology and Aging 8(3): 463; Morin, C.M. (1993) Insomnia: Psychological Assessment and Management. New York, NY: Guilford Press.

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• unrealistic expectations about sleep (e.g. ‘I need to sleep eight hours every day’) • catastrophizing about the consequences of poor sleep (e.g. ‘if I don’t sleep now, I will be late, lose my job and my family will leave me’) • lack of confidence in the control of sleep (e.g. ‘my sleep is totally out of control’) • unhelpful beliefs about sleep-promoting behaviours (e.g. ‘if I don’t meditate half an hour before going to bed, I will have a bad night’s sleep’). These beliefs tend to create negative thinking both in bed and during the day. Insomnia patients constantly think about how bad their sleep was, is and will be, and spend consistent amounts of time monitoring potential signs and symptoms of perceived sleep deprivation. They experience persistent negative emotions such as failure, worry, hopelessness, helplessness and frustration, which explain the autonomic and cortical arousal observed 24 hours a day in insomnia patients. In Chinese medicine, cognitions and emotions are entangled into a unique system of seven qingzhi. Thinking (si), which is associated with earth and the centre, functions as a pivot to shift emotions. Negative thinking and emotions tend to make the qi go inward and create stagnation. As the function of the liver is to drain qi movements and emotions, this stagnation is often called ‘liver qi stagnation’. This qi stagnation can produce heat and fire, which correspond to the physiological arousal associated with insomnia. As we will see in Part B, emotion-induced liver qi stagnation is one of the core features of insomnia pathology. In the last 20 years, the rise of mindfulness and related therapies has influenced the research on the psychological factors of insomnia. The focus shifted from the content of cognitions to the relationship we have with internal processes such as thinking, emotions…and sleep. Harvey observed the cognitive strategies of insomnia patients and found they tend to use thought control, imagery control, emotional inhibition and problem-solving strategies to cope with rumination, negative emotions and physiological arousal in bed.10 These dysfunctional strategies increase the negative processes instead of decreasing them. 10 Harvey, A.G. (2002) A cognitive model of insomnia. Behaviour Research and Therapy 40(8): 869–893.

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In Chinese medicine, the control of thoughts and emotions is associated with the inhibiting and descending movement of the metal. The metal controls the wood and provokes an inhibition of the draining function of the liver, leading to liver qi stagnation. More recently, Espie proposed the attention–intention–effort pathways to explain the maintaining of chronic insomnia. Sleep is supposed to be an automatic process, but insomnia patients tend to focus their attention on sleep, including monitoring of the environment for sleep-related threats, trying to fall asleep and adopting active efforts to fall asleep.11 As these efforts activate autonomic and cortical arousal, the more the patient tries to fall asleep, the less successful he is. In Chinese medicine, the attention (yi) is controlled by the spleen and guides the qi wherever it goes (‘yi dao ze qi dao’). The focus of attention on sleep and sleep-related threats provokes a collection of qi, leading to qi stagnation. Here we find again (liver) qi stagnation as a core pathological mechanism of insomnia. Daoist tradition teaches us to ‘follow the natural (shun qi ziran)’ and adopt effortless actions (wuwei). Adopting active efforts to control internal processes leads only to negative emotions which increase the stagnation and fire, and therefore disturb the shen.

3. Risk factors Female sex, old age, poor lifestyle habits, poor global health and certain types of constitution and personality traits are associated with insomnia. These factors are usually not considered as ‘causes’ of insomnia in the main psychophysiopathological models of insomnia but rather as increasing the risk of developing insomnia. This distinction is irrelevant in Chinese medicine as we tend to consider both direct and indirect causes and mechanisms of diseases using complex pathological models. Zhang and Wing conducted a systematic review of cross-sectional studies including more than one million participants and found that females are more prone to insomnia than males, with an overall risk ratio of 1.41 [95% CI, 1.28–1.55].12 This is consistent with the gender ten11 Espie, C.A., Broomfield, N.M., MacMahon, K.M.A., Macphee, L.M. and Taylor, L.M. (2006) The attention–intention–effort pathway in the development of psychophysiologic insomnia: A theoretical review. Sleep Medicine Reviews 10(4): 215–245. 12 Zhang, B. and Wing, Y.-K. (2006) Sex differences in insomnia: A meta-analysis. Sleep 29(1): 85–93.

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dency of many mental disorders such as depression and anxiety.13 The male/female ratio peaks around 50 years old, which is usually explained by menopause.14 Due to menstruation, pregnancy, labour and lactation, females are more prone to blood deficiency than males. In Chinese medicine, the liver, which drains the qi movements and emotions, uses blood to function. Relative blood deficiency explains why females are more prone than males to mood disorders. The lack of blood is temporarily accentuated before menstruation, after childbirth and at menopause, which are periods in which mental disorders are common. Blood deficiency disturbs the draining function of the liver, leading to insufficient draining (qi stagnation) or excessive draining (liver fire), sometimes both alternately. In Part B, we will see that blood deficiency is not a main pattern of insomnia but is rather a central mechanism in the pathology of insomnia. The relationship between insomnia and age is not as clear. Most of the epidemiologic studies found a positive correlation between age and insomnia, yet this relation was not linear in all the studies.15 Some studies found a decrease in prevalence among the elderly after 60–65 years of age.16 This may be partially explained by the end of menopause and the 13 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 14 Xiang, Y.T., Ma, X., Cai, Z.J., Li, S.R. et al. (2008) The prevalence of insomnia, its sociodemographic and clinical correlates, and treatment in rural and urban regions of Beijing, China: A general population-based survey. Sleep 31(12): 1655–1662; Hsu, Y.W., Ho, C.H., Wang, J.J., Hsieh, K.Y. et al. (2013) Longitudinal trends of the healthcare-seeking prevalence and incidence of insomnia in Taiwan: An 8-year nationally representative study. Sleep Medicine 14(9): 843–849. 15 Hsu, Y.W., Ho, C.H., Wang, J.J., Hsieh, K.Y. et al. (2013) Longitudinal trends of the healthcare-seeking prevalence and incidence of insomnia in Taiwan: An 8-year nationally representative study. Sleep Medicine 14(9): 843–849; Morin, C.M., LeBlanc, M., Bélanger, L., Ivers, H., Mérette, C. and Savard, J. (2011) Prevalence of insomnia and its treatment in Canada. The Canadian Journal of Psychiatry 56(9): 540–548; Morin, C.M., LeBlanc, M., Daley, M., Gregoire, J.P. and Mérette, C. (2006) Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine 7(2): 123–130; Morphy, H., Dunn, K.M., Lewis, M., Boardman, H.F. and Croft, P.R. (2007) Epidemiology of insomnia: A longitudinal study in a UK population. Sleep 30(3): 274–280. 16 Castro, L.S., Poyares, D., Leger, D., Bittencourt, L. and Tufik, S. (2013) Objective prevalence of insomnia in the São Paulo, Brazil epidemiologic sleep study. Annals of Neurology 74(4): 537–546; Xiang, Y.T., Ma, X., Cai, Z.J., Li, S.R. et al. (2008) The prevalence of insomnia, its sociodemographic and clinical correlates, and treatment in rural and urban regions of Beijing, China: A general population-based survey. Sleep 31(12): 1655–1662; Morin, C.M., LeBlanc, M., Bélanger, L., Ivers, H., Mérette, C. and Savard, J. (2011) Prevalence of insomnia and its treatment in Canada. The Canadian Journal of Psychiatry 56(9): 540–548.

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beginning of a less stressful life in retirement. Sleep is known to evolve with age, with shorter sleep duration and lighter sleep in older adults. Advanced sleep rhythm disorder is also common in older adults. In the CERs we have analysed, two sociodemographic subgroups of insomnia were the focus of attention of the clinicians: perimenopausal women and older adults (see Part B). Both types of insomnia were associated with the yin deficiency and fire pathological system compared with insomnia in younger patients which was associated with the liver qi stagnation pathological system. Insomnia in perimenopausal women was associated with blood deficiency, kidney deficiency and fire, which is typical of the perimenopausal constitution. Insomnia in older adults was associated with kidney deficiency and coldness, but not blood stasis. Epidemiological studies also found a correlation between lifestyle and insomnia. Obesity and poor lifestyle habits such as smoking, drinking alcohol, watching TV and physical inactivity are risk factors for insomnia.17 The effect of impaired sleep hygiene on insomnia will be discussed in the next chapter. According to Chinese medicine, a sedentary lifestyle, lack of physical activity and excessive food intake and drinking harm the spleen, causing spleen deficiency. According to the clinical experience synthesis, spleen deficiency is a key factor in the pathological mechanism of insomnia. Spleen deficiency is more closely associated with the Heart-Spleen Deficiency pattern and Phlegm-Heat pattern but is widely present as a background feature in most patterns. Indeed, the atypical stomach disharmony pattern of insomnia spreads across several typical patterns of insomnia, including the Yin Deficiency with Effulgent Fire pattern. Protecting the spleen and stomach is also one of the main concerns of herbalists. Chinese medicine theory allows us to understand the importance of non-sleep-related lifestyle factors in the mechanism of insomnia. Cross-sectional studies also found an association between poor

17 Benbir, G., Demir, A., Aksu, M. and Ardic, S. (2015) Prevalence of insomnia and its clinical correlates in a general population in Turkey. Psychiatry and Clinical Neurosciences 69(9): 543–552; Uhlig, B.L., Sand, T., Odegård, S.S. and Hagen, K. (2014) Prevalence and associated factors of DSM-V insomnia in Norway: The Nord-Trøndelag Health Study (HUNT 3). Sleep Medicine 15(6): 708–713; Xiang, Y.T., Ma, X., Cai, Z.J., Li, S.R. et al. (2008) The prevalence of insomnia, its sociodemographic and clinical correlates, and treatment in rural and urban regions of Beijing, China: A general population-based survey. Sleep 31(12): 1655–1662; Ohayon, M.M. and Smirne, S. (2002) Prevalence and consequences of insomnia disorders in the general population of Italy. Sleep Medicine 3(2): 115–120.

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global health and insomnia.18 However, the mechanism by which poor global health contributes to insomnia from a biomedicine perspective is unclear. We will see in Part B that chronic medical conditions and poor constitution are considered to be some of the main causes of the Yin Deficiency with Effulgent Fire pattern along with aging, as they provoke kidney deficiency, liver-kidney deficiency or heart-kidney deficiency, which in turn leads to heart fire (see Chapter 6). Constitution and personality have also a role to play in the pathology of insomnia. Anxiety or a worry-prone personality or cognitive style, increased arousal predisposition and tendency to repress emotions can increase vulnerability to insomnia.19 We will see in Chapter 9 that Chinese medicine clinicians also consider that constitution (e.g. yin deficiency, qi stagnation) and personality (e.g. introverted, sensitive) increase vulnerability to insomnia. Moreover, they show that certain constitutions and personality traits increase vulnerability for certain patterns of insomnia. Poor constitution is usually associated with the yin deficiency and fire system, while personality traits such as introversion, depressed mood and irritability are associated with the liver qi stagnation system.

4. Insomnia and comorbidities Insomnia was traditionally divided into primary insomnia (i.e. insomnia that is not explained by another condition) and secondary insomnia (i.e. insomnia caused by another disorder such as depression disorder or cancer). The idea was that, in the case of secondary insomnia, treatment should target only the primary condition and not the symptoms of insomnia. Sleep researchers found that primary and secondary insomnia share common pathological mechanisms (such as cortical hyperarousal and psychological maintaining factors) and do not differ in terms of response to treatment.20 Moreover, the causal relation between

18 Roth, T. and Roehrs, T. (2003) Insomnia: Epidemiology, characteristics, and consequences. Clinical Cornerstone 5(3): 5–15; Jansson-Fröjmark, M. and Lindblom, K. (2008) A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. Journal of Psychosomatic Research 64(4): 443–449. 19 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 20 Stepanski, E.J. and Rybarczyk, B. (2006) Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Medicine Reviews 10(1): 7–18.

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insomnia and the ‘primary’ condition was seen as unclear and variable.21 As such, the reliability and viability of the primary insomnia diagnosis was challenged22 and finally abandoned in both the DSM-523 and the ICSD-3.24 It does not mean that insomnia is not related to other physical or mental conditions. However, the diagnosis of insomnia disorder is reached as long as the other criteria are met. If the patient has other health conditions (regardless of the effect on sleep), these conditions are called ‘comorbidities’. Anxiety and depression are common comorbidities of insomnia.25 Emotional, cortical and cognitive arousal is a core feature of anxiety and depression. This arousal impairs the sleep of anxious and depressive patients, which explains why anxiety and depression are risk factors for the development of insomnia.26 We saw above that a core feature of insomnia is worry about not getting enough sleep, and feelings of helplessness (e.g. ‘nothing works’) and hopelessness (e.g. ‘my sleep can’t be fixed’) are common. These negative beliefs are usually limited to sleep, yet sometimes a generalization occurs (e.g. ‘I will get sick, lose 21 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 22 Buysse, D.J., Reynolds, C.F., Hauri, P.J., Roth, T. et al. (1994) Diagnostic concordance for DSM-IV sleep disorders: A report from the APA/NIMH DSM-IV field trial. The American Journal of Psychiatry 151(9): 1351; Edinger, J.D., Wyatt, J.K., Stepanski, E.J., Olsen, M.K. et al. (2011) Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses: Results of a multitrait-multimethod analysis. Archives of General Psychiatry 68(10): 992–1002. 23 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 24 American Academy of Sleep Medicine (2014) International Classification of Sleep Disorders (3rd edn). Darien, IL: American Academy of Sleep Medicine. 25 Castro, L.S., Poyares, D., Leger, D., Bittencourt, L. and Tufik, S. (2013) Objective prevalence of insomnia in the São Paulo, Brazil epidemiologic sleep study. Annals of Neurology 74(4): 537–546; Uhlig, B.L., Sand, T., Odegård, S.S. and Hagen, K. (2014) Prevalence and associated factors of DSM-V insomnia in Norway: The Nord-Trøndelag Health Study (HUNT 3). Sleep Medicine 15(6): 708–713; Morin, C.M., LeBlanc, M., Daley, M., Gregoire, J.P. and Mérette, C. (2006) Epidemiology of insomnia: Prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Medicine 7(2): 123–130; Sivertsen, B., Krokstad, S., Øverland, S. and Mykletun, A. (2009) The epidemiology of insomnia: Associations with physical and mental health: The HUNT-2 study. Journal of Psychosomatic Research 67(2): 109–116; Terauchi, M., Hiramitsu, S., Akiyoshi, M., Owa, Y. et al. (2012) Associations between anxiety, depression and insomnia in peri- and post-menopausal women. Maturitas 72(1): 61–65. 26 Morphy, H., Dunn, K.M., Lewis, M., Boardman, H.F. and Croft, P.R. (2007) Epidemiology of insomnia: A longitudinal study in a UK population. Sleep 30(3): 274–280; Jansson, M. and Linton, S.J. (2006) The role of anxiety and depression in the development of insomnia: Cross-sectional and prospective analyses. Psychology and Health 21(3): 383–397.

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my job, lose my mind’, ‘I’m a total failure’). This explains why insomnia is also a risk factor for the development of anxiety and depression.27 Therefore, there is a bidirectional causality link between, on the one hand, anxiety and depression and, on the other hand, insomnia.28 Other mental disorders such as eating disorders, personality disorders and schizophrenia can also be comorbid with insomnia.29 Insomnia can also be comorbid with physical and systemic diseases such as hypertension, heart diseases, arthritis, lung and ear–nose–throat diseases, stomach conditions and diabetes mellitus.30 Again, the causal relationship between insomnia and these comorbidities is likely to be bidirectional.31 One of the main somatic factors associated with insomnia is pain, which can disturb sleep and also be caused or aggravated by insomnia.32 As Chinese medicine is a holistic medicine that treats not only the disease but the person as a whole, the question of comorbidities is fundamental in the treatment of insomnia with Chinese medicine. We will see in Chapter 12 that the relationship between insomnia and the comorbidity is complicated, yet the comorbidity is more often 27 Morphy, H., Dunn, K.M., Lewis, M., Boardman, H.F. and Croft, P.R. (2007) Epidemiology of insomnia: A longitudinal study in a UK population. Sleep 30(3): 274–280; Ohayon, M.M. and Roth, T. (2003) Place of chronic insomnia in the course of depressive and anxiety disorders. Journal of Psychiatric Research 37(1): 9–15; Riemann, D. and Voderholzer, U. (2003) Primary insomnia: A risk factor to develop depression? Journal of Affective Disorders 76(1): 255–259; Taylor, D.J., Lichstein, K.L. and Durrence, H.H. (2003) Insomnia as a health risk factor. Behavioral Sleep Medicine 1(4): 227–247. 28 Jansson-Fröjmark, M. and Lindblom, K. (2008) A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. Journal of Psychosomatic Research 64(4): 443–449. 29 Baglioni, C., Nanovska, S., Regen, W., Spiegelhalder, K. et al. (2016) Sleep and mental disorders: A meta-analysis of polysomnographic research. Psychological Bulletin 142(9): 969; Benca, R.M., Obermeyer, W.H., Thisted, R.A. and Gillin, J.C. (1992) Sleep and psychiatric disorders: A meta-analysis. Archives of General Psychiatry 49(8): 651–668; Soehner, A.M., Kaplan, K.A. and Harvey, A.G. (2013) Insomnia comorbid to severe psychiatric illness. Sleep Medicine Clinics 8(3): 361–371. 30 Benbir, G., Demir, A., Aksu, M. and Ardic, S. (2015) Prevalence of insomnia and its clinical correlates in a general population in Turkey. Psychiatry and Clinical Neurosciences 69(9): 543–552; Zhang, J.H., Lam, S.P., Li, S.X., Yu, M.W.M. et al. (2012) Long-term outcomes and predictors of chronic insomnia: A prospective study in Hong Kong Chinese adults. Sleep Medicine 13(5): 455–462. 31 Roberts, R.E., Ramsay Roberts, C. and Chan, W. (2008) Persistence and change in symptoms of insomnia among adolescents. Sleep 31(2): 177–184; Roberts, R.E., Roberts, C.R. and Duong, H.T. (2008) Chronic insomnia and its negative consequences for health and functioning of adolescents: A 12-month prospective study. Journal of Adolescent Health 42(3): 294–302. 32 Morphy, H., Dunn, K.M., Lewis, M., Boardman, H.F. and Croft, P.R. (2007) Epidemiology of insomnia: A longitudinal study in a UK population. Sleep 30(3): 274–280.

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considered the cause than the other way around. Pattern theory adds a level to the pathological mechanism of diseases. The treatment often targets the unique underlying mechanism of both insomnia and the comorbidity – that is, the pattern. Nonetheless, treatment strategies are complex and include treating the ‘primary’ condition alone, treating insomnia alone or treating both with different combinations of treatment.

5. Summary The core pathological mechanism of insomnia is cortical hyperarousal, which is linked to a lack of balance between sleep-promoting systems (i.e. homeostatic and circadian drive) and sleep-inhibition systems (i.e. the limbic system acting on the ARAS). Many reasons, such as excessive caffeine consumption, acute stress and jet lag, can lead to cortical hyperarousal, which explains why insomnia symptoms and acute insomnia are so prevalent in the general population. Chronic insomnia appears to be due to the development of behavioural factors (e.g. excessive time awake in the sleep environment) and cognitive factors (e.g. worrying about the potential consequences of insomnia, active intention and effort to fall sleep, dysfunctional cognitive strategies), which impair sleep conditioning and create stress reaction, leading to cortical arousal. Female sex, old age, poor lifestyle habits, constitution and personality traits and comorbidities all play a role in the development of insomnia disorder. The perception of the pathological mechanism of insomnia by Chinese medicine clinicians shares many similarities with the current models proposed by sleep specialists. Heart heat/fire and shen agitation, which are similar to cortical hyperarousal, are considered the endpoint of the pathological development of insomnia. Emotion-induced liver qi stagnation, which is similar to the Western concept of stress reaction, is considered a core mechanism of insomnia. However, Chinese medicine considers lifestyle factors such as excessive diet and overstrain and biological factors such as constitution and long-term diseases as direct factors of insomnia (especially for the yin deficiency with fire system and the heart-spleen deficiency system), whereas they are only considered as risk factors in modern sleep medicine.

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Chapter 4

The Treatment of Insomnia This chapter covers the different treatment options for insomnia, including both conventional and alternative treatments. Chinese medicine treatments are not covered in this chapter as they will be discussed in more detail in Part B. Pharmaceutical drugs and cognitivebehavioural therapy for insomnia (CBT-I) are currently the only treatments recommended by authoritative guidelines.1 Pharmaceutical drugs and sleep hygiene are the most commonly used by primary care clinicians.

1. Pharmaceutical drugs Pharmacotherapy, and especially benzodiazepine receptor agonist (BzRA) drugs, is by far the most commonly used treatment for insomnia. Pharmaceutical drugs used to improve sleep are called hypnotic drugs. They include barbiturates, benzodiazepine receptor agonists, antihistamines and melatonin. Some non-hypnotics are also used in the treatment of insomnia. Barbiturates were traditionally used to treat insomnia as well; due to their high toxicity and dependency, however, they were progressively replaced by BzRAs from the 1950s. BzRAs have dominated the pharmacologic treatment of insomnia since

1

Qaseem, A., Kansagara, D., Forciea, M.A., Cooke, M. et al. (2016) Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine 165(2): 125–133; Ree, M., Junge, M. and Cunnington, D. (2017) Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults. Sleep Medicine 36(s1): S43–S47; Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B. et al. (2017) European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research 26(6): 675–700; Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C. and Sateia, M. (2008) Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine 4(5): 487–504.

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the 1960s.2 They are composed of two groups, the benzodiazepines (e.g. triazolam, temazepam, flurazepam, estazolam, quazepam) and the newer ‘Z-drugs’ (e.g. zolpidem, zolpidem CR, zaleplon, eszopiclone). Gammaaminobutyric acid (GABA) is an inhibitory neurotransmitter widely present in the central nervous system. Benzodiazepines and Z-drugs both act on the GABAA receptor and potentiate the action of GABA, resulting in a global inhibition of the central nervous system (CNS).3 The effect of BzRAs on sleep can be likened to the force shutdown command of a computer when the normal shutdown command is not responding. The use of BzRAs is supported by strong empirical evidence in various populations (adults and children, comorbid insomnia, etc.) and a long history of clinical use. Due to the wide presence of GABA receptors in the CNS, BzRAs can induce a large range of adverse effects, including morning sedation, anterograde amnesia, anxiety, falls, undesired sleep behaviour and somatic symptoms,4 leading some sleep experts to question the benefit/risk ratio of BzRAs for older adults.5 BzRA use is also associated with a higher risk of developing cancer, dementia, pneumonia and allcause mortality.6 Dependency, as manifested by rebound insomnia and withdrawal symptoms, is also a concern.7 Finally, insomnia levels return to pre-treatment levels two years after discontinuation of the treatment,8 2 3 4

5 6

7 8

Krystal, A.D. (2010) Benzodiazepine Receptor Agonists: Indications, Efficacy and Outcomes. In M.J. Sateia and D.J. Buysse (eds) Insomnia: Diagnosis and Treatment. Boca Raton, FL: CRC Press. Bateson, A.N. (2010) Pharmacology of the GABAA Receptor Complex. In M.J. Sateia and D.J. Buysse (eds) Insomnia: Diagnosis and Treatment. Boca Raton, FL: CRC Press. Schutte-Rodin, S., Broch, L., Busses, D., Dorsey, C. and Sateia, M. (2008) Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine 4(5): 487–504; Walsh, J.K. and Roth, T. (2011) Pharmacologic Treatment of Insomnia: Benzodiazepine Receptor Agonists. In M.H. Kryger, T. Roth and W.C. Dement (eds) Principles and Practices of Sleep Medicine. Glendenning, Australia: Saunders. Glass, J., Lanctôt, K.L., Herrmann, N., Sproule, B.A. and Busto, U.E. (2005) Sedative hypnotics in older people with insomnia: Meta-analysis of risks and benefits. British Medical Journal 331(7526): 1169. de Gage, S.B., Bégaud, B., Bazin, F., Verdoux, H. et al. (2012) Benzodiazepine use and risk of dementia: Prospective population based study. BMJ 345: 1–12. Iqbal, U., Nguyen, P.A., Syed-Abdul, S., Yang, H.C. et al. (2015) Is long-term use of benzodiazepine a risk for cancer? Medicine 94(6): 1–8. Obiora, E., Hubbard, R., Sanders, R.D. and Myles, P.R. (2013) The impact of benzodiazepines on occurrence of pneumonia and mortality from pneumonia: A nested case-control and survival analysis in a population-based cohort. Thorax 68(2): 163–170; Kripke, D.F., Langer, R.D. and Kline, L.E. (2012) Hypnotics’ association with mortality or cancer: A matched cohort study. BMJ Open 2(1): 1–8. Buysse, D.J. (2013) Insomnia. JAMA 309(7): 706–716. Morin, C.M., Colecchi, C., Stone, J., Sood, R. and Brink, D. (1999) Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. JAMA 281(11): 991–999.

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which can lead some people to think that BzRAs do not cure the root of the illness. Melatonin is associated with circadian cycle regulation, which is one of the main drivers of sleep. Melatonin and melatonin receptor agonists such as ramelteon are gaining popularity as an alternative to BzRA drugs. The main reason is that melatonin receptors are more specific than GABA receptors, and therefore melatonin and related drugs are associated with fewer side effects. Recent meta-analyses found them more effective than placebo, yet with a smaller effect than BzRAs.9 Melatonin seems an ideal treatment for sensitive populations such as children and older adults and for insomnia comorbid with circadian rhythm disorders.10 As mentioned previously, orexin neurons of the lateral hypothalamus are involved in the regulation of sleep. Their role is to enhance the activity of the ARAS and therefore maintain wakefulness. Suvorexant, a dual orexin receptor antagonist that selectively binds to orexin-1 and -2 receptors, has been found effective to improve sleep, although adverse events such as somnolence, fatigue and abnormal dreams are reported.11 This promising alternative to BzRAs has been approved recently and more time is needed to judge its long-term effects. H1-antihistamine drugs are widely used for allergic conditions. The H1 receptor is not only present in mast cells (involved in allergic reaction) but also in the tuberomamillary nucleus, in which histaminergic neurons are involved in cortical arousal. H1-antihistamine drugs that pass the blood–brain barrier (e.g. diphenhydramine) inhibit these excitory neurons, producing a sedative effect. For this reason, over-the-­counter H1-antihistamines are often used off-label or as a self-medication for insomnia. Sedative antidepressants (e.g. trazodone, amitriptyline, 9

Ferracioli-Oda, E., Qawasmi, A. and Bloch, M.H. (2013) Meta-analysis: Melatonin for the treatment of primary sleep disorders. PLOS ONE 8(5): e63773; Kuriyama, A., Honda, M. and Hayashino, Y. (2014) Ramelteon for the treatment of insomnia in adults: A systematic review and meta-analysis. Sleep Medicine 15(4): 385–392. 10 van Geijlswijk, I.M., Korzilius, H.P. and Smits, M.G. (2010) The use of exogenous melatonin in delayed sleep phase disorder: A meta-analysis. Sleep 33(12): 1605–1614; Wei, S., Smits, M.G., Tang, X., Kuang, L. et al. (2020) Efficacy and safety of melatonin for sleep onset insomnia in children and adolescents: A meta-analysis of randomized controlled trials. Sleep Medicine 68: 1–8; Herxheimer, A. and Petrie, K.J. (2002) Melatonin for the prevention and treatment of jet lag. Cochrane Database of Systematic Reviews 2002(2): CD001520. 11 Morin, C.M., LeBlanc, M., Bélanger, L., Ivers, H., Mérette, C. and Savard, J. (2011) Prevalence of insomnia and its treatment in Canada. The Canadian Journal of Psychiatry 56(9): 540–548.

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doxepin, mirtazapine) promote sleep not through a sedative action but through resynchronization of the circadian rhythm. Because of the perceived threat of dependency from BzRAs, prescriptions of antidepressants for insomnia exceeded the prescriptions of BzRAs in the 1990s in the US.12 Other drugs used off-label for insomnia include antipsychotic drugs (e.g. quetiapine, olanzapine), which have antihistaminic activities, and anticonvulsants (e.g. gabapentin, pregabalin, valproic acid, tiagabine), which have GABAergic activities. With the exception of the antidepressant doxepin, none of these drugs is approved for the treatment of insomnia and the evidence of clinical efficacy is scarce. Because of their adverse reactions and the lack of evidence of benefit for the patient, institutions recommend against the use of antihistamine, antidepressant, antipsychotic and anticonvulsant drugs. Understanding pharmaceutical drugs from a Chinese medicine perspective allows us to draw parallels and integrate Western and Chinese medicine for better outcomes. BzRAs can be likened to heavy-­ sedative shen-calming herbs such as longgu and muli. They are useful for improving symptoms quickly but fail to improve the underlying pathophysiology of the conditions (e.g. heat, stagnation, blood deficiency). Chinese herbal treatments can be combined with BzRAs in order to reduce the adverse reactions and provide more in-depth regulation. Caution should be taken for the Heart-Spleen Deficiency pattern, for which BzRAs may not be suited. Melatonin and related drugs are more similar to blood-nurturing shen-calming herbs such as suanzaoren or baiziren. They may be useful for blood-deficiency types of insomnia and mild insomnia, yet herbs should be added to target more severe and non-blood-deficiency types of insomnia. Antihistamine drugs are similar to wind herbs such as qianghuo and fangfeng. Antidepressant drugs are similar to liver-draining herbs such as chaihu and chuanxiong. They can be useful for insomnia, especially for Liver Stagnation and Phlegm-Heat patterns, but tend to dry the yin and should be combined with yin-nurturing herbs if needed. Finally, antipsychotic drugs have heat-clearing and shen-calming properties. They may be appropriate in the case of severe heart and liver fire. Herbs can be combined with antipsychotic drugs to limit their adverse reactions.

12 Walsh, J.K. (2004) Drugs used to treat insomnia in 2002: Regulatory-based rather than evidence-based medicine. Sleep 27(8): 1441–1442.

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2. Cognitive-behavioural therapy for insomnia Cognitive-behavioural therapy for insomnia (CBT-I) refers to a set of cognitive and behavioural interventions that target insomnia. Due to the high-quality evidence for its short-term and long-term efficacy, as well as a virtual absence of adverse reactions, CBT-I is now recommended as a first-line treatment for insomnia. The core of the treatment package consists of stimulus-control therapy (SCT), sleep-restriction therapy (SRT) and cognitive therapy, usually combined with relaxation training, sleep hygiene and sometimes phototherapy. Sleep hygiene is relatively traditional and widely used in primary care settings as a standalone intervention and will be described separately. SCT aims at re-establishing sleep conditioning (the association between sleep and the bed, the bedroom and bedtime) with the following behavioural instructions: 1. Go to bed only when sleepy. 2. Use the bed only for sleep and sexual activities. 3. Get up and go into another room if unable to fall asleep or fall back asleep after waking up. 4. Go back to bed only if you feel sleepy again. Repeat point 3 if necessary. 5. Get up at the same time every morning. 6. Do not nap during the day. In SRT, the time the patient spends in bed is limited by a fixed bedtime and rising time. The rationale is to limit time in bed to the sleep capacity of the patient and avoid any time spent awake in bed. For example, if the patient can sleep on average six hours in total, he/she may be asked to go to bed not later than 12 p.m. and get up not earlier than 6 a.m. Generally, SCT and SRT increase the sleep pressure, adjust the circadian cycle and instil a beneficial conditioning from the sleep environment. They also tend to facilitate cognitive changes as the patient already acts as if they were less concerned, anxious and fused with their sleeping problems. As we saw earlier, the suffering related to trouble sleeping leads people to change their perspective on sleep. Insomniacs tend to develop a lack of confidence in the control of sleep (note that sleep was never under their control in the first place, but they would still be confident about controlling it), catastrophize about the consequences of poor sleep, have unrealistic expectations about sleep and believe they need

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Treating Insomnia with Chinese Medicine

some substance or ritual to achieve good sleep. The goal of cognitive therapy is to change these harmful beliefs into more beneficial beliefs such as ‘it’s OK if I don’t sleep eight or even six hours every night’, which in turns reduces negative affects (e.g. anxiety) and harmful behaviours. The techniques used to achieve this goal include psychoeducation (i.e. providing information), Socratic questioning, role play (e.g. the therapist plays a patient with unhelpful beliefs and the patient tries to convince him/her to change), behavioural tests, attentional shift and imagery training. Mindfulness-based therapies have recently been added to the palette of psychological interventions for insomnia. With mindfulness, the goal is not to change the content of thoughts and beliefs but to change the patient’s relationship with these cognitions. In mindfulness, we observe passively thoughts and internal processes (e.g. wakefulness status) instead of actively trying to change them. In other words, the patients learn to not fight and struggle against their own thoughts and wakefulness. Cognitive changes are relatively more difficult to achieve than behavioural changes (which depend solely upon compliance with instructions) but lead to more sustained changes than behavioural changes alone. For this reason, optimal outcomes are achieved with a combination of SCT, SRT and cognitive therapy. Relaxation training such as progressive muscle relaxation (PMR), diaphragmatic breathing, autogenic training and imagery training13 are sometimes added to the core components of CBT-I. The goal is not to achieve one-time relaxation in the therapist’s clinic but to teach the patient a technique that can be used independently on a regular basis to reduce levels of autonomic arousal. It is important that the technique is not used as a ‘quick fix’ to get rid of insomnia symptoms, as it can lead to anxiety (‘what if it does not work this time?’), frustration (‘damn, even this does not work’) and a misunderstanding of the goal of CBT-I (i.e. cognitive and behavioural changes). Phototherapy (i.e. light therapy) is not, strictly speaking, a form of psychotherapy, yet it is sometimes included in CBT-I treatment ‘packages’. Patients are exposed to white light produced by a phototherapy device emitting on average 2500 lux while they are reading or eating, or

13 Perlis, M.L. (2005) Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer.

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The Treatment of Insomnia

during similar activities.14 This exposure, which simulates exposure to sunlight, can affect the SCN and readjust the circadian rhythm.15 Phototherapy is particularly useful for insomnia when the patient presents mostly with either difficulty falling asleep or early-morning awakening. Generally, CBT-I tends to focus on the psychological aspects of insomnia (thoughts, negative affects, autonomic arousal) and may be more suited for the liver stagnation system of insomnia, especially for conditions related to liver qi stagnation, liver and heart fire, and blood deficiency. The ability of CBT-I to change constitutional deficiencies such as Heart-Spleen Deficiency and Kidney Yin Deficiency can be questioned. As liver qi stagnation is sometimes difficult to overcome with herbs alone, a combination of CBT-I and Chinese medicine can be considered depending on the situation.

3. Sleep hygiene Even though CBT-I is recommended as a first-line treatment for insomnia, it requires more training and resources to conduct than sleep hygiene education. As a result, sleep hygiene education is currently the most widely used psychological intervention for insomnia.16 Sleep hygiene education refers to instructions about sleep-related behaviours. Although there is no consensus about the content of these instructions, the core recommendations are:17 • • • • •

avoid caffeine avoid nicotine avoid alcohol exercise regularly manage stress

14 Taylor, D.J., Grieser, E.A. and Tatum, J.I. (2010) Other Nonpharmacological Treatments of Insomnia. In M.J. Sateia and D.J. Buysse (eds) Insomnia: Diagnosis and Treatment. Boca Raton, FL: CRC Press. 15 Sack, R.L., Auckley, D., Auger, R.R., Carskadon, M.A. et al. (2007) Circadian rhythm sleep disorders: Part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep–wake rhythm. An American Academy of Sleep Medicine review. Sleep 30(11): 1484–1501. 16 Sivertsen, B., Nordhus, I.H., Bjorvatn, B. and Pallesen, S. (2010) Sleep problems in general practice: A national survey of assessment and treatment routines of general practitioners in Norway. Journal of Sleep Research 19(1 Pt 1): 36–41. 17 Irish, L.A., Kline, C.E., Gunn, H.E., Buysse, D.J. and Hall, M.H. (2015) The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep Medicine Reviews 22: 23–36.

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• reduce bedroom noise • keep a regular sleep schedule • avoid daytime naps. More recent instructions are inspired by SCT, SRT, cognitive therapy and mindfulness approaches such as ‘limit time in bed’ or ‘do not try to fall asleep’. There is an association between poor sleep hygiene and poor sleep quality in non-insomniac populations.18 However, the sleep hygiene practices of insomnia patients are not different from those of good sleepers.19 This may be due to the fact that insomniacs are generally worried about their sleep and tend to avoid sleep-harming behaviours. Although widely used in primary care practices, there is no evidence that sleep hygiene education alone provides a specific effect for the treatment of insomnia.20

4. Mind–body therapies and exercise Mind–body therapies are physical, spiritual and artistic practices in which mindfulness is a core aspect. Mindfulness is a state of self-­ awareness achieved by self-regulation of attention so that it is maintained on immediate experience and by adopting an orientation to the present moment that is characterized by curiosity, openness and acceptance.21 Mind–body therapies include traditional practices such as tai chi, qigong, yoga and meditation, and modern approaches such as relaxation training, hypnotherapy, music therapy and dance therapy. Mind–body therapies tend to emphasize the integration of the mind and body to improve wellbeing. The health benefits of mind–body therapies are broad, including increased energy, decreased depression and anxiety, 18 Brown, F.C., Buboltz Jr, W.C. and Soper, B. (2002) Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behavioral Medicine 28(1): 33–38; Knufinke, M., Nieuwenhuys, A., Guerts, S.A.E., Coenen, A.M.L. and Kompier, M.A.J. (2018) Self-reported sleep quantity, quality and sleep hygiene in elite athletes. Journal of Sleep Research 27(1): 78–85. 19 Harvey, A.G. (2000) Sleep hygiene and sleep-onset insomnia. The Journal of Nervous and Mental Disease 188(1): 53–55. 20 Stepanski, E.J. and Wyatt, J.K. (2003) Use of sleep hygiene in the treatment of insomnia. Sleep Medicine Reviews 7(3): 215–225; Chung, K.-F., Lee, C.-T., Yeung, W.-F., Chan, M.-S., Chung, E.W.-Y. and Lin, W.-L. (2018) Sleep hygiene education as a treatment of insomnia: A systematic review and meta-analysis. Family Practice 35(4): 365–375. 21 Bishop, S.R., Lau, M., Shapiro, S., Carlson, L. et al. (2004) Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice 11(3): 230–241.

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The Treatment of Insomnia

decreased stress (as measured with biological markers), decreased pain, sleep quality improvements and stronger immune system. Mind–body therapies seem ideal interventions for insomnia for several reasons. The first is the emphasis on mindfulness. Mind–body therapies teach the patient to use a curious and open attitude that can be used to break the attention–intention–effort pathway of insomnia and thought-control processes. The second reason is that mind–body therapies can reduce stress. From a biological perspective, this means that the excitation of the ARAS by the limbic system is reduced, leading to less cortical arousal. From a psychosocial perspective, this means the patient spends less time engaging in problem solving, is less depressed about past failures and less anxious about future threats. The third reason is that mind–body therapies can reduce bodily discomfort such as pain, an aspect particularly important in comorbid insomnia. There is now evidence that meditation, tai chi, qigong and yoga can significantly improve sleep quality in insomnia patients.22 An exciting finding is that mind–body therapies can increase total sleep time, which is difficult to achieve with CBT-I.23 As insomnia patients view themselves as sleep-deprived, they tend to conduct less physical activity, which reduces sleep quality. As such, it seems logical to propose exercise therapy to insomnia patients. Recent research showed that exercise can help to improve the sleep of insomnia patients, especially to improve sleep onset latency.24 Mind–body therapies and exercise can both be considered as liver-draining practices which are helpful in regulating emotions. In mind–body therapies, there is an emphasis on connecting the heart and the kidney and calming the shen. In exercise therapy, there is an emphasis on burning the fire and letting it out through sweating. Therefore, mind–body therapies may be more helpful with deficiency patterns of insomnia, and exercise more helpful with excess patterns of 22 Mustian, K.M. (2013) Yoga as treatment for insomnia among cancer patients and survivors: A systematic review. European Medical Journal: Oncology 1: 106; Wang, X., Li, P., Pan, C., Dai, L., Wu, Y. and Deng, Y. (2019) The effect of mind-body therapies on insomnia: A systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine 2019: 30894878. 23 Gong, H., Ni, C.-X., Liu, Y.-Z., Zhang, Y. et al. (2016) Mindfulness meditation for insomnia: A meta-analysis of randomized controlled trials. Journal of Psychosomatic Research 89: 1–6. 24 Lowe, H., Haddock, G., Mulligan, L.D., Gregg, L. et al. (2019) Does exercise improve sleep for adults with insomnia? A systematic review with quality appraisal. Clinical Psychology Review 68: 1–12.

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insomnia. Both can be relatively easily combined with Chinese medicine treatments such as acupuncture and herbal medicine.

5. Summary In summary, pharmacological treatments have a reliable short-term efficacy, but are associated with adverse reactions, dependency and long-term risks. CBT-I is a safe and effective therapy, yet it is not widely available for insomnia patients. Although widely used in primary care settings, there is little evidence that sleep hygiene is an appropriate intervention for people with insomnia. Mind–body therapies and exercise are good alternatives to pharmacological treatments and CBT-I. From a Chinese medicine perspective, some interventions might be more appropriate than others depending on the pattern. For example, CBT-I, antidepressant drugs, mind–body therapies and exercise could be more useful for patients with liver qi stagnation (as we will see in Part B, this is one of the core mechanisms of insomnia). For patients with strong fire, BzRA drugs and even antipsychotic drugs could be more appropriate options. Melatonin and mind–body therapies could be more helpful for patients with yin-blood deficiency. We will see in Chapter 23 several options for the integration of Chinese medicine with Western medicine and psychological interventions.

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Part B

Clinical Experience Synthesis

Chapter 5

General Considerations in the Treatment of Insomnia with Chinese Medicine This chapter explores the different modalities used for insomnia and global strategies used to treat insomnia such as options in the case of absence of treatment response. It provides an overview of the Chinese medicine diagnostic model and treatment model for insomnia.

1. Treatment modalities The two main models used by clinicians are the pattern-differentiation model and the disease-differentiation model. In the former, the diagnosis is based on patterns of signs and symptoms and a specific treatment is given for each pattern. In the latter, one single formula is used in every case of insomnia. In both cases, the treatment can be modified according to specific signs and symptoms and other considerations such as the age, comorbidities and constitution of the patient. The pattern-differentiation model is preferred by clinicians who use herbal medicine (58%), whereas the disease-differentiation model is preferred by clinicians who use acupuncture (80%) and massage (80%) (Figure 5.1.). Most clinicians use either one model or the other; however, the two models can be used simultaneously. For example, one clinician uses a disease approach with herbs that regulate the yinyang and calm the spirit when there is not enough evidence for pattern differentiation. Another clinician generally uses a disease approach but changes to a pattern-specific treatment in the case of blood stasis or food stagnation. The modification of the main formula in the disease approach according to the pattern is common and sometimes a disease-based treatment is

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Treating Insomnia with Chinese Medicine

added to the pattern-based formula. In the latter case, the purpose of the added disease-based treatment is generally to calm the spirit and sometimes to improve qi circulation. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Herbal medicine

Acupuncture Paern

Massage

Disease

Figure 5.1. Percentages of therapeutic models used according to the treatment modality

Some clinicians propose a stepped-care approach. This means that different therapeutic approaches can be used depending on the severity of the condition. In one four-step model, cognitive-behavioural therapy is proposed as the first step, then non-pharmacological Chinese medicine methods such as acupuncture and massage are used as the second step, Chinese herbal medicine is used as the third step, and, finally, Western medicine is used as the fourth step (1). Another clinician proposes a therapeutic course composed of acupuncture needling first, then moxibustion, fire needles or bloodletting according to the condition of the patient, and ear acupuncture or buried needle at the end of the treatment (1). In the case of absence of treatment response, three approaches can be used in addition to a reassessment followed by an appropriate treatment. These approaches are used regardless of the signs and symptoms of the patient. The first approach is the treatment of blood stasis with Xue Fu Zhu Yu Tang (4). The second approach is the treatment of yang deficiency with warm-tonifying herbs such as huangqi, yinyanghuo, guizhi, fuzi and ganjiang, and oppressing-immersing herbs such as wuweizi, cishi, longgu, muli or guijia (3). This approach is used especially when yin-nurturing and spirit-calming methods are ineffective (2) and can be used only when there is no significant sign of yang-heat (1). The third approach is the treatment of phlegm with Wen Dan Tang (1).

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Considerations in the Treatment of Insomnia with Chinese Medicine

2. Diagnostic model of insomnia The two basic diagnostic approaches in Chinese medicine are the pattern approach and the disease approach (Figure 5.2.). In the pattern approach, the diagnosis is based mainly on the signs and symptoms (SSs) of the patient. The seven typical patterns and five atypical patterns of insomnia can be observed across various conditions, yet the SSs and associated treatments of these patterns is influenced by the disease diagnosis (i.e. insomnia). The cause of the disease (e.g. excessive emotions), the sociodemographic characteristics of the patient (e.g. gender, age), the constitution of the patient (e.g. yin deficiency constitution), the personality of the patient (e.g. introverted), the comorbidities of the patient (e.g. hypercholesterolemia) and the location (e.g. humid location or large city with high stress levels) are also taken into account to identify the pattern diagnosis. Causes Sociodemographics Constitution Personality Comorbidities Location

Comorbidities

Disturbed shen

Signs and symptoms → Paern

Diagnosis

Main complaint → Disease (mechanism)

Yin Def with Fire Liver Qi Stagnation Liver Fire Phlegm-Heat Blood Stasis Liver-Spleen Dis Heart-Spleen Def

Atypical paerns Stomach Disharmony Qi/Yang Deficiency Nut-Prot Disharmony Non-Interaction H-K Heart-Gall Deficiency

Liver Qi Stagnation

Figure 5.2. Main diagnostic approaches in the treatment of insomnia with Chinese medicine

The primary disease diagnosis (i.e. insomnia) provides a framework to understand insomnia patients. The core feature of insomnia is a disturbed shen (i.e. spirit), and its primary pathological mechanism is liver qi stagnation. The secondary pathological mechanisms of insomnia are liver/heart fire, blood-yin deficiency and phlegm. The secondary

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Treating Insomnia with Chinese Medicine

disease diagnosis (i.e. comorbidities) provides important information to understand the context of the disease. It can provide an explanation for insomnia (in which case the treatment should target the comorbidity), provide guidance to understand the pattern (i.e. pathological mechanism) and can suggest a complex treatment plan that addresses both insomnia and the comorbidity.

3. Treatment model of insomnia The three basic treatment modalities for the treatment of insomnia with Chinese medicine are Chinese herbal medicine, acupuncture and massage (Figure 5.3.). For acupuncture and massage, the points (zones) and techniques are mainly selected on the basis of the disease. The treatment aims to regulate yinyang (excess of yang and lack of yin are one of the core mechanisms of insomnia), regulate qi movements (liver qi stagnation is the primary mechanism of insomnia) and regulate brain-spirit (the brain-spirit controls sleep). The treatment can also be based on or adapted according to the pattern of the patient. The clinical reasoning for Chinese herbal medicine is more complex. The treatment is generally based on the pattern diagnosis, which includes seven typical patterns and five atypical patterns. The treatment is then modified according to secondary patterns and symptoms. Some clinicians prefer a disease-based treatment which targets the core feature of insomnia (i.e. disturbed shen), the primary mechanism of insomnia (i.e. liver qi stagnation), the global mechanism of insomnia with either a narrow approach (i.e. Suan Zao Ren Tang) or a wide approach (big and varied formulas), or based on the clinician’s individual understanding of insomnia’s pathology. The main formula can then be modified according to the pattern of the patient. In both the pattern and the disease approach, the clinician should consider the season, the geographic location, the constitution of the patient, the comorbidities of the patient, the demographic characteristics of the patient and the protection of the spleen-stomach and the yin, and modify the formula accordingly. In addition to the formula itself, the clinician should also choose a modality (i.e. decoction, paste, infusion) and preparation and intake methods that are appropriate for the patient. Besides the ‘core’ treatment with herbs, acupuncture and/or massage, the clinician should give pattern-based and disease-based

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Considerations in the Treatment of Insomnia with Chinese Medicine

recommendations to the patient and provide self-treatment methods. The psychological aspect of the consultation and various psychological interventions must also be considered. Finally, the clinician should consider the need to integrate the Chinese medicine treatment with Western medicine and psychotherapy. Pa ern-based treatment Modality Modification Season Constitution Comorbidities Location Demographics Protect spleen and yin

Preparation/ intake

Seven typical pa erns Five atypical pa erns

Herbs

Shen-calming Big and varied Liver-smoothing Suan Zao Ren Tang Individual perspective

Disease-based treatment Life cultivation Psychology Integration

Treatment

Massage Zones/techniques

Yingyang regulation Qi movements Regulate brain-spirit

Acupuncture

Points/ techniques

Pa ern-based treatment

Disease-based treatment

Figure 5.3. Important considerations in the clinical reasoning for the treatment of insomnia with Chinese medicine

61

Chapter 6

Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine This chapter is the pillar of the chapters on Chinese herbal medicine. It presents the typical patterns (those in which there is a clear direction in terms of treatment) of insomnia with the causal relationship between them, the associated population, SSs, formulas and individual herbs. Modification methods and clinical tips are also presented.

1. Generalities 1.1. Causes and mechanisms Only causes and mechanisms cited at least six times were included in Figure 6.1. A total of nine different mechanisms and nine causes were included in the final model. These nine main mechanisms are: • • • • • • • • •

liver stagnation blood stasis phlegm-heat liver blood deficiency liver fire spleen deficiency heart-spleen deficiency kidney yin deficiency heart fire.

According to the clinicians, the primary causes of insomnia are:

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

• • • • • • • • •

emotions excessive thinking excessive diet alcohol intake constitution overstrain severe or long-term diseases aging excessive sexual life.

The most extensively cited cause is ‘emotions’, with 122 citations, and the most extensively cited mechanism is ‘liver stagnation’, with 114 citations. Some causes can provoke different mechanisms – for example, emotions causing either liver stagnation, liver blood deficiency, liver fire or heart fire. Some mechanisms can have different causes – for example, kidney yin deficiency can be caused by constitution, severe or long-term disease, aging, excessive sexual life and overstrain. Complex causal relationships, sometimes bidirectional, were identified between the above causes and mechanisms or between two mechanisms. Three main ‘systems’ of causes and mechanisms can be identified – that is, the liver stagnation system, the yin deficiency and fire system, and the heart-spleen deficiency system. In the first system, liver stagnation caused by excessive emotions is the primary mechanism, leading to four secondary mechanisms – liver fire, phlegm-heat, blood stasis and liver blood deficiency. Emotions, overthinking and excessive diet can also create or aggravate phlegmheat, liver fire and liver blood deficiency. For healthy people, insomnia is mainly caused by preoccupation and emotions. Zhangshi Yitong

In the second system, kidney yin deficiency and heart fire are intertwined. The primary causes of these are different, kidney yin deficiency being caused by consumption through aging, diseases and overstrain, and heart fire being caused by excessive emotions. Ultimately, these two mechanisms aggravate each other and form a cluster. This system

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Treating Insomnia with Chinese Medicine

is connected to the ‘liver stagnation’ system via liver blood deficiency and liver fire. Blood stasis (14)

Long-term

Food accumulation

Emotions (83), excessive thinking (7)

Long-term

Emotions (8), constitution (7)

Excessive diet (17), excessive thinking (6)

Constitution (20), severe or long-term disease (15), aging (11), excessive sexual life (7), overstrain (6)

Phlegmheat (43)

Liver stagnation (114)

Excessive diet (20), alcohol intake (8)

Transformation into fire

Liver blood deficiency (30)

Liver fire (64)

Emotions (10)

HeartSpleen Source spleen deficiency insufficient deficiency (39) (29)

Excessive thinking (26), overstrain (10)

Kidney yin deficiency (35)

Emotions (11)

Heart fire (25)

Figure 6.1. Flowchart of the causes and mechanisms leading to insomnia described by the authors in the context of Chinese herbal medicine treatment with a pattern approach Causes are presented in boxes and mechanisms are presented in circles. Arrows show a causality relationship and dotted lines show some proximity between two mechanisms. The text inlaid on the arrows represents additional descriptions of the causality relationship by the author. Causes have been placed on both sides of the flowchart to allow better readability of the chart.

In the third system, heart-spleen deficiency is caused directly or indirectly through spleen deficiency by excessive diet, excessive thinking or overstrain. This system is relatively independent but can be connected to the ‘liver stagnation’ system by liver stagnation causing spleen deficiency. It is important to understand that these ‘mechanisms’ are different from ‘patterns’ represented in this study by clusters of formulas.

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

Mechanisms were expressed directly by the authors of the CERs, whereas patterns were identified through computerized cluster analysis. In order to differentiate them, we capitalized the patterns but not the mechanisms. Some patterns may be associated with two or more mechanisms (e.g. Yin Deficiency with Effulgent Fire associated primarily with kidney yin deficiency, liver blood deficiency and heart fire), while some mechanisms and patterns overlap (e.g. heart-spleen deficiency and HeartSpleen Deficiency).

1.2. Overview of patterns Seven patterns were identified through cluster analysis and labelled ‘Yin Deficiency with Effulgent Fire’, ‘Phlegm-Heat’, ‘Heart and Spleen Deficiency’, ‘Liver Fire’, ‘Liver Stagnation’, ‘Blood Stasis’ and ‘Classical Formulas’ (Table 6.1). Table 6.1 shows the number of formulas for each pattern, which indicates how widely this pattern is considered as a major pattern of insomnia by the community of clinicians, which may be influenced by how common this pattern presents in the clinic. The heterogeneity represents the internal consistency of the pattern. For example, a pattern that includes several major formulas will be considered highly heterogeneous. The specificity of the pattern reflects how different from the other patterns is this pattern. It is assessed based on the specificity of the individual herbs and SSs of the pattern. Table 6.1. Characteristics of the seven patterns identified through cluster analysis Pattern ID

Label

Abbreviation

Most common formula

Number of formulas

Heterogeneity

Specificity

1

‘Yin Deficiency with Effulgent Fire’

Yin-DefFire

Huang Lian E Jiao Tang

89 (23%)

High

Relatively low

2

‘Liver Stagnation’

Liver Stag

Dan Zhi Xiao Yao San

55 (14%)

Relatively high

Low

3

‘Liver Fire’

Liver Fire

Long Dan Xie Gan Tang

20 (5%)

Low

Low

4

‘PhlegmHeat’

PhlegmHeat

Wen Dan Tang

75 (19%)

Relatively low

High

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Treating Insomnia with Chinese Medicine Pattern ID

Label

Abbreviation

Most common formula

Number of formulas

Heterogeneity

Specificity

5

‘Blood Stasis’

Blood Stasis

Xue Fu Zhu Yu Tang

26 (7%)

Low

High

6

‘Heart and Spleen Deficiency’

H-S Def

Gui Pi Tang

45 (12%)

Low

Relatively high

7

‘Classical Formulas’

Class For

Suan Zao Ren Tang

78 (20%)

High

Low

The difference between the present categorization of pattern and other possible categorizations of patterns that were pre-selected is the number of clusters related to ‘Yin Deficiency with Effulgent Fire’, ranging from one (in the present categorization) to a maximum of four (labelled ‘Non-Communication Between Heart and Kidney’, ‘Heart Blood Deficiency’, ‘Liver Blood Deficiency’ and ‘Kidney Deficiency’). Another variation is the formulas included in the ‘Classical Formulas’ pattern, which included Huang Lian E Jiao Tang and Zhu Sha An Shen Wan in some categorizations.

1.3. Overview of formulas Among the 438 formulas for which the name of the formula was expressed by the author, 189 different formulas were cited (Figure 6.2). The most commonly cited formulas were Gui Pi Tang (30), Suan Zao Ren Tang (22), Wen Dan Tang (21), Xue Fu Zhu Yu Tang (21), Huang Lian Wen Dan Tang (20), Huang Lian E Jiao Tang (19), Dan Zhi Xiao Yao San (18), Long Dan Xie Gan Tang (16), Chai Hu Shu Gan San (13) and Chai Hu Jia Long Gu Mu Li Tang (10). The ten most cited formulas accounted for 43% of all the formulas. 1.4. Pattern differentiation The key signs and symptoms allowing for pattern differentiation are presented in Figure 6.3. This model is able to predict patterns with an overall correct prediction rate of 55.4%. Some patterns are more easily identified through SSs than others. The correct prediction rate is 82.0% for ‘Yin Deficiency with Effulgent Fire’, 0.0% for ‘Classical Formulas’, 57.3% for ‘Phlegm-Heat’, 46.7% for ‘Spleen and Heart Deficiency’, 65.0% for ‘Liver Fire’, 38.2% for ‘Liver Stagnation’ and 65.4% for ‘Blood Stasis’. This decision tree is based on 304 patterns for which at least one sign or symptom was described. 66

Sheng Mai Yin and Bai He Di Huang Tang self-designed Song Yu An Shen Fang Shu Gan An Shen Tang self-designed Tiao Bu Tang Wu Mei Tang Shu Gan He Wei Wan

Gan Mai Da Zao Tang

Suan Zao Zhen Hun Tang Gui Zhi Jia Long Gu Mu Li Tang

Chai Hu Jia Long Gu Mu Li Tang

Liu Wei Di Huang Wan

Shu Gan He Wei Wan Ban Xia Shu Mi Tang

Bao He Wan and Zhi Zhu Wan

The size of the words depends on the number of citations.

Figure 6.2. Word cloud of the names of the formulas mentioned by the authors

Chai Hu Wen Dan Tang Ping Wei San

Dao Chi San and Zhu Sha An Shen Wan He Wei An Shen Tang Shuang Xia Wen Dan Tang Wen Shi Ben Tun Tang Zhi Gan Cao Tang Yi Qi Zhen Hun Tang Gui Pi Tang and Er Chen Tang Tiao Wei Cheng Qi Tang Dang Gui Lu Hui Wan

Ma Zi Ren Wan

Liu Wei Di Huang Wan and Jiao Zhu Sha An Shen Wan An Shen Ding Zhi Wan

Xue Fu Zhu Yu Tang Dan ZhiBaoXiao Yao San He Wan

Shi Wei Wen Dan Tang

Wen Dan Tang Liu Wei Di Huang Wan and Jiao Tai Wan Gui Fu Di Huang Wan Chai Hu Gui Zhi Tang Gui Zhi Gan Cao Long Gu Mu Li Tang Fu Ling Si Ni Tang Tao Hong Si Wu Tang Huang Qi Jian Zhong Tang Yi Shen Zhen Hun Tang Jin Ding Tang Qian Yang Feng Sui Dan Li Zhong Qian Yang Dan Bu Shen Qing Xin An Shen Tang

Shen Zi Yang Tang Si Wu Tang and Suan Zao Ren Tang Zhi Zhi Shi Dao Zhi Wan

Tian Ma Gou Teng Yin

Si Ni San

Wen Dan Tang Chai Hu Shu Gan San

An Shen Ding Zhi Wan and Suan Zao Ren Tang

Ban Xia Xie Xin Tang

Tai Wan

Tian Wang Bu Xin Dan

Hua Yu An Shen Tang Zhi Zi Chi Tang Xiao Chai Hu Tang

Gui Zhi Tang

Xiao Yao San

Jiao Tai Wan Si Jun Zi Tang

Gui Pi Tang

Jiao Tai Wan

Suan Zao Ren Tang Huang Lian E Jiao Tang

Zhu Sha An Shen Wan

San Tiao Tang

Huang Lian Wen Dan Tang Shen Qi Wan

Ban Bai Zhen Hun Tang Bu Mei Xiao Fang An Shen 2 Hao Fang self-designed Xiao Yao Si Ni San self-designed Qing Tang Ning Shen Fang Si Ni Tang and Gui Zhi Gan Cao Long Gu Mu Li Tang Jia Yi Gui Zang Tang Suan Zao Ren Tang and Si Wu Tang Xue Fu Zhu Yu Tang and Ci Zhu Wan Yue Ju Wan Liang Ji Zhen Hun Tang Bu Xin Zhuang Dan An Shen Tang Zhu Ling Tang Sheng Yang Yi Wei Tang Yi Guan Jian and Suan Zao Ren Tang Bai He Di Huang Tang Yang Xin Tang Bu Pi Zhi Shen Tang Dan Zhi Xiao Yao San and Huang Liang Wen Dan Tang Liu Wei Di Huang Wan and Huang Lian E Jiao Tang Qi Ju Di Huang Wan self-designed An Shen Fang Xiao Jian Zhong Tang Xiao Qing Long Tang Mian An Tang Qing Gan Huan Hun Jian Xiao Yao San and Bu Zhong Yi Qi Tang Qu Qie Zhi Shen Tang Meng Shi Gun Tan Wan Xiao Yao San and Suan Zao Ren Tang Liu Wei Di Huang Wan self-designed An Mian Fang Shu Gan An Shen Tang Si Ni Tang and Si Ni San and Gui Zhi Gan Cao Long Gu Mu Li Tang Yue Ju Bao He Wan Bai He Zhi Mu Tang Er Xian Zhen Hun Tang Xiao Chai Hu Tang and Chang Pu Yu Jin Tang and Zhi Zi Chi Tang Long Dan Xie Gan Tang and Yi Wei Tang Xiang Sha Liu Jun Zi Tang Zhu Ye Shi Gao Tang Liu Jun Zi Tang Huang Lian Wen Dan Tang and An Shen Ding Zhi Wan Yi Guan Jian Bu Yang Huan Wu Tang and Suan Zao Ren Tang Di Zhuo Fang Xiao Chai Hu Tang and Huang Lian Wen Dan Tang Qing Gong Tang Song Yu An Shen Fang and Suan Zao Ren Tang Si Tiao Tang Huang Tu Tang Zhi Bai Di Huang Wan Zhen Gan Xi Feng Tang Dan Bai Tang Bai He Di Huang Tang and Ban Bai Zhen Hun Tang Yang Yin Zao Ren An Shen Tang Zhen Zhu Mu Wan Bu Gan San Huan Shao Dan Gan Dan Liang Yi Tang and Wu You San Xiao Chai Hu Tang and Gui Zhi Jia Long Gu Mu Li Tang Yi Guan Jian Gui Pi Tang Huang Lian E Jiao Tang and Chai Hu Jia Long Gu Mu Li Tang Wen Dan Tang and Xiao Chai Hu Tang Bai He Gui Pi Tang Xiao Chai Hu Tang and Gui Zhi Gan Cao Long Gu Mu Li Tang Zhu Sha An Shen Wan Chai Qin Wen Dan Tang Zhu Ye Shi Gao Tang and Zhi Zi Chi Tang Dang Gui Liu Huang Tang Huang Lian E Jiao Tang and Jiao Tai Wan Xiao Chai Hu Tang and Wen Dan Tang Huang Lian Wen Dan Tang and Zhi Zi Chi Tang Yi Gong San and Jiao San Xian Zhi Shen Zhong Ning Tang Ban Xia Shu Mi Tang and Wen Dan Tang Shi Yi Wei Wen Dan Tang Chai Hu Shu Gan San and Zuo Jin Wan Chai Shao Wen Dan Tang Er Xian Tang Zhi Zi Chi Tang and Da Huang Huang Lian Xie Xin Tang and Yue Ju Wan Long Dan Xie Gan Tang Xiao Yao Zhen Hun Tang Wen Dan An Shen Tang Fu Zi Li Zhong Tang Bai He Gan Mai Tang Zi Shui Qing Gan Yin An Shen Ding Zhi Wan Liu Wei Di Huang Wan and Tian Wang Bu Xin Dan Zhi Shi Zhi Zi Chi Tang Yi Guan Jian and Zhu Ye Shi Gao Tang Zhi Shen Qing An Tang Long Dan Xie Gan Tang and Xie Qing Wan Zhu Sha An Shen Wan and Huang Lian E Jiao Tang Zhu Sha An Shen Wan and Zhi Zi Chi Tang Yi Shen Zhuang Yang Tang An Shen Ding Zhi Wan and Gui Pi Tang Li Zhong Wan Huang Lian E Jiao Tang and Tian Wang Bu Xin Dan Bu Qi Yang Xue An Shen Tang Jie Yu An Shen Tang Liu Wei Di Huang Wan and Zhi Zi Chi Tang Wen Dan Tang and Suan Zao Ren Tang Zhi Bai Di Huang Tang Xie Re Ban Xia Qian Li Liu Shui Tang Zhi Bai Di Huang Wan

Tang and Suan Zao Ren Tang Long Dan Xie Gan Tang GuiBanPi Xia Hou Po Tang

self-designed Shou Wu San Jiao Tai Wan and Suan Zao Ren Tang Hua Yu Huan Hun Jian Long Dan Xie Gan Tang self-designed Shuang Lian Tang Suan Ren An Hun Tang

Huang Lian E Jiao Tang and Tian Wang Bu Xin Dan

Treating Insomnia with Chinese Medicine

NO

NO

Weak pulse

NO

NO

NO

NO

Choppy pulse

Greasy coating

YES

Dark urine in small quantity

Forgetfulness

YES

Thready pulse

YES

Side distension

YES

NO

‘Liver Fire’ (46.4%)

‘Yin Deficiency with Effulgent Fire’ (40.0%)

YES

YES

Irritability YES YES

NO

‘Yin Deficiency with Effulgent Fire’ (32.6%)

‘Liver Stagnation’ (47.4%)

‘Liver Stagnation’ (70.6%)

‘Yin Deficiency with Effulgent Fire’ (71.6%)

‘Heart and Spleen Deficiency’ (84.0%)

‘PhlegmHeat’ (74.1%)

‘Blood Stasis’ (89.5%)

Figure 6.3. Decision tree of the signs and symptoms allowing for differentiation of patterns The percentage of cases belonging to the pattern is shown in brackets.

2. Typical patterns 2.1. Yin Deficiency with Effulgent Fire The original results of the cluster analysis included Suan Zao Ren Tang in this pattern. Due to the absence of specificity of Suan Zao Ren Tang in terms of herbs and SSs, the fact that Suan Zao Ren Tang can be included in different patterns depending on the cluster analysis parameters, and the fact that Suan Zao Ren Tang is a major classical formula, it was changed from the Yin Deficiency with Effulgent Fire pattern to the Classical Formulas pattern. 2.1.1. Yin-Def-Fire population characteristics and signs/symptoms This pattern is commonly observed in older adults (4) and white-collar workers (2). This pattern is also associated with persistent insomnia (2).

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

When there is preoccupation, taxation, panic and worry but no other influence and there is frequent insomnia, it is always a case of lack of essence and blood. Jingyue Quanshu

The SSs indicating Yin-Def-Fire are represented in Figure 6.4. The eight most common SSs of Yin-Def-Fire are: 1. 2. 3. 4. 5. 6. 7. 8.

agitation (48% sen, 27% spe) fine pulse (42% sen, 32% spe) red tongue (30% sen, 26% spe) rapid pulse (29% sen, 26% spe) frequent dreams (24% sen, 18% spe) palpitations (24% sen, 22% spe) pale tongue (21% sen, 21% spe) dry mouth (21% sen, 36% spe).

One high-specificity SS was identified: faint pulse (2% sen, 100% spe). The most common tongue and pulse features associated with YinDef-Fire are: 1. red tongue (30%, 35%) 2. pale tongue (26%, 36%) 3. wiry and thin pulse (19%, 61%) 4. thin coating (16%, 30%) 5. thin and rapid pulse (15%, 82%) 6. white coating (14%, 27%) 7. lack of coating (11%, 82%) 8. yellow coating (11%, 16%) 9. weak and thin pulse (7%, 24%) 10. heavy and thin pulse (6%, 54%) 11. rapid pulse only (4%, 71%) 12. wiry, slippery and rapid pulse (3%, 100%) 13. slippery pulse only (3%, 36%) 14. wiry and rapid pulse (3%, 14%).

69

wiry pulse

thick coatingvertigo

frequent sigh suspicion severe fever

tip of tongue red

cough

dry stools

nocturnal emission large tongue

sterility

obesity

confusion

no agitation

red eyes

headaches

thinness

black complexion

aversion to cold thorax ache

choppy pulse

sweat

head confusion abundant water intake

The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

Figure 6.4. Signs and symptoms associated with the Yin Deficiency with Effulgent Fire pattern

all-night insomnia

paroxysmic cold sweat

stuffy chest

red complexion cracked tongue pale complexion

breathlessness hands and feet hot

dizziness

frequent urination

dry mouth at night

weak pulse

abdominal bloating

hiccup moist pulse

urine light and abundant

blurred vision

impotence

panic awakenings

lower back and legs cold

preference for cold drinks

normal appetite

abdominal discomfort

dysuria

deep pulse

aversion to wind

depression

abdominal pain

nightmares

rapid pulse

green complexion sticky stools

bone-evaporating fever early morning awakenings

heat in thorax

so stools and diarrhoea fever

limb numbness

petechia on tongue night sweating irregular menstruations dry throat

thin pulse difficulty falling asleep

dream emission

lack of coating

relaxed pulse

watery coating

frequent awakenings

somnolence

eructationssomniloquy lower back and knee sore and so

anxiety

tinnitus

dry mouth without thirst

light tongue

hot feeling when urinating

oedema strong pulse

head heaviness

frequent dreams dry mouth constipation slippery pulse

hot flushes

tendency to craziness

defecation not smooth

greasy coating

dry tongue

mouth ulcers

blocked throat

haematuria overthinking

urine dark and scant

purple tongue withered nails

red tongue yellow coating

spontaneous sweat thin coating

fatigue

easily startled explosion feeling in head

agitation

light sleep cold extremities

bier taste in mouth

abnormal sweat

faint pulse

stabbing pain in head

white head coating distension

palpitations

lack of aention dispersed pulse aversion to speech insomnia aggravated by panic dark pale tongue absence of coating

acid reflux and heartburn

gastric bloating

forgetfulness

mess (zaoza)

dry eyes

foreign object sensation in throat aversion to heat painful urination

abundant phlegm stomach reversion thirst nausea and vomiting

dark complexion yellow complexion stomach discomfort lack of appetite irritability

slow pulse frequent night urination congested vessels under tongue light red tongue light nails premature ejaculation

Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

The most specific tongue and pulse features associated with Yin-DefFire are: 1. wiry, slippery and rapid pulse (3%, 100%) 2. relaxed and thin pulse (2%, 100%) 3. dark pale tongue (1%, 100%) 4. cracked tongue (1%, 100%) 5. fainting pulse only (1%, 100%) 6. dispersed pulse only (1%, 100%) 7. thin and slippery pulse (1%, 100%) 8. heavy and weak pulse (1%, 100%) 9. thin and rapid pulse (15%, 82%) 10. lack of coating (11%, 82%) 11. dry tongue (2%, 75%) 12. rapid pulse only (4%, 71%). 2.1.2. Prescriptions for Yin-Def-Fire The herbs used for Yin-Def-Fire are represented in Figure 6.5.

jizihuang yejiaoteng maidong zexie baizirenyuanzhi bohe

hehuanhua yujin

zhishi

shengjiang

huangqi

huangqin rougui dahuang

heye

huashi

longchi

zhuru

muxiang

houpo

shudihuang

baizhu

guizhi

longgu

renshen danshen

suanzaoren wuweizi danpi

huanglian gancao

shanyao

gouqizi suye

huangbai banxia

chaihu

baihe

danzhuye

ganjiang

mangxiao

fushen

yinyanghuo

chuanxiong fuzi zhenzhumu

longdancao

zhimu

xuanshen taoren longyanrou

zhuye

xianmao

zhusha

zhuling

honghua

shihu

dangshen

hehuanpi luhui

chenpi

zishiying

lianzixin

zhizi

cishi

ejiao shanyzhuyu baishao fuling shengdi shigao

bajitian shenqu

mutong tiandong chishao xiaomai

chuanlianzi laifuzi

shumi

muli

beishashen zaoxintu

shijueming

tianma

danggui dandouchi hupo

chenxiang

changpu

guijia jixueteng mengshi gouteng

heshouwu

Figure 6.5. Herbs used for the Yin Deficiency with Effulgent Fire pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

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The seven most common herbs for Yin-Def-Fire are reported in Table 6.2. Table 6.2. Information on the core herbs of the Yin-Def-Fire pattern Herb (sen, spe)

Mean dose (min–max)

Type

Notes

Huanglian (45%, 50%)

9.9g (6–15g)

Baishao (33%, 26%)

11.8g (6–15g)

Hang (1)

Fuling (31%, 14%)

15.4g (10–20g)

Yunnan (1)

Suanzaoren (31%, 19%)

30.0g (15–50g)

Chao (3)

Huangqin (28%, 34%)

9.5g (6–15g)

Indicated for all kinds of heat (1).

Shengdi (28%, 34%)

15.0g (10–20g)

Use high doses, usually up to 30–50g (1).

Ejiao (28%, 96%)

11.1g (6–20g)

Melt separately (yanghua) (2). Salty flavour can soften and tonify (1). An ingredient of blood, flesh and emotions (xuerou youqing zhi pin) (1)

Indicated for all kinds of heat (1). Its bitter flavour can remove heat (1). Can nurture kidney water when combined with ejiao and jizihuang, can bring down heart fire when combined with huanglian and huangqin (1). Its sour flavour can collect the yinqi and drain the evil heat (1).

The formula is modified according to seven different situations (Table 6.3). Table 6.3. Modifications according to symptoms or pattern for the Yin-Def-Fire pattern Pattern

Main signs/symptoms

Main added herbs

Yin deficiency (5)

Dry mouth (4), agitation (3)

Shengdi (8), maidong (7), wuweizi (5)

Fire (6)

Agitation (7)

Zhizi (5), huanglian (4)

 

Palpitations (5), severe insomnia (3), frequent panic (3), frequent dreams (3)

Longgu (7), muli (4), yejiaoteng (4)

72

Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine Qi deficiency (6)

Fatigue (4), shortness of breath (4)

Huangqi (6)

Blood deficiency (4)

Palpitations (2)

Danggui (4)

 

Constipation (3) with dry stools (2) and abdominal bloating (2)

Zhishi (3), houpo (2), dahuang (2)

Stagnation (2)

 

Yujin (3), xiangfu (2)

2.1.3. Clinical pearls for Yin-Def-Fire The authors expressed 20 recommendations regarding the Yin-Def-Fire pattern, including: 1. ‘This type is frequently observed in the clinic.’ 2. This type is relatively easy to treat if the diagnosis is precise (1). 3. These patients usually present signs of autonomous system impairment such as fast heart rate, thin body and having difficulty staying calm (1). 4. Bitter taste in mouth and dark urine are enough to indicate the use of Bai He Zhi Mu Tang (1). 5. ‘When using this formula [Zhu Ling Tang]…use the original dose for each herb; do not use it if the patient is sweating.’ 6. ‘Need to add appropriately qi-regulating herbs in order to keep the three burners free and herbs that warm and strengthen the spleen-stomach.’ 7. ‘You should not remove jizihuang [in Huang Lian E Jiao Tang]; it cannot be replaced by soft-boiled chicken eggs; otherwise the efficacy will decrease.’ 8. ‘This formula [Ban Xia Shu Mi Tang] is too simple and has to be combined with other classic formula.’ 9. When using yin-nurturing herbs, you need to combine them with yang-immersing herbs such as longgu, muli, guijia, biejia or shijueming (2). They have to be used raw and in high doses (1). 10. You need to add yin-nurturing herbs such as zhimu, hanliancao or baihe to fire-draining herbs; otherwise you will not be able to drain the fire (1). 11. As you know that the condition of the liver will affect the spleen, use fushen, lianzi and shanyao to prevent the weakening of the spleen (1).

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Treating Insomnia with Chinese Medicine

12. Animal products such as ejiao, ziheche, guijia or biejia can be used in cases of severe yin-blood deficiency (1). 13. ‘Avoid too many rich (zini 滋腻) yin-nurturing herbs because it would be like trying to fight fire with firewood.’ 14. ‘Fire-descending herbs such as huangbai and zhimu are excessively bitter, cold and water-draining, their coldness can damage the stomach… Use instead zhuye and zhizi which are fragrant and cool, they open the orifice of the heart and move down heart fire.’ 15. ‘As older and chronic patients often have spleen-stomach disharmony, add in the formula herbs that waken the spleen and open the stomach such as sharen or zhiqiao, so you can tonify without stagnation and nurture without accumulating; you can also use jiao sanxian to strengthen the spleen and harmonize the stomach.’ 16. Huang Lian E Jiao Tang is bitter, cold and slimy, so it cannot be used for a long period. It can be replaced by Liu Wei Di Huang Wan after improvement (1). 17. ‘Food therapy is important. Light food, easy to digest and full of nutrients [is recommended] to help the production of qi and blood.’ 18. ‘You should not treat this type of patient [An Shen Ding Zhi Wan pattern] with medication only; they must be trained psychologically to improve their adaptation capacities.’ A 46-year-old male consulted for insomnia for one month. He presented with agitation, insomnia, dry mouth and throat, headaches, dizziness, lower back soreness and seminal emission during dreams. His tongue was red with a lack of coating and his pulse was thin and wiry. He had a history of hypertension for ten years and his blood pressure (BP) was 161/98 mmHg. This is a pattern of kidney yin deficiency with strong heart fire. He was prescribed Huang Lian E Jiao Tang: ejiao 11g (dissolved), huanglian 9g, huangqin 6g, baishao 12g, shanzhuyu 10g, gouqizi 10g, guijia 20g, baiziren 15g, suanzaoren 15g. After five bags the sleep was improved, and after ten further bags his BP decreased to 146/90 mmHg and the symptoms were removed.

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

2.2. Liver Stagnation 2.2.1. Liver Stag population characteristics and signs/symptoms The populations associated with Liver Stag are young people (3), females (3), middle-aged people (2) and white-collar workers (2). This pattern is also associated with depression (2). The liver of healthy people is not attacked by evils, thus when they go to bed the hun returns to the liver, the shen is calm and they sleep. Now, there is evil in the liver, the hun cannot return, thus when the patient goes to bed the hun ascends as if it was leaving the body. Puji Benshi Fang

The SSs indicating Liver Stag are reported in Figure 6.6.

fatigue needling pain in the back, thorax and abdomen

tongue agitation red lack of activity

gastric bloating urine dark and scant thirst dry eyes

anxiety

light sleep large tongue

greasy coating lack of appetite side pain thready pulse

headache

oral ulcer dysmenorrhea

oppressive pain in the back, thorax and abdomen

frequent sigh

lower belly distension relaxed pulse

tongue tip red dry stools overthinking borborygmi dark red tongue blocked throat side running pain eructation

frequent dreams body ache

dull complexion

wiry pulse

sore muscles sleepiness normal stools emotion-induced symptoms

forgetfulness

breast distension and pain

head confusion

diarrhoeawhite coating

tinnitus

lower belly ache

vertigo

vexation

frequent panic

fatigue at rising

frequent awakenings

dry throat red complexion

lack of speech

constipation

bier mouth

pale tongue

red eyes

electric sensation hiccup

difficulty falling asleep

head distension

irregular stools thorax ache

rapid pulse side distension slippery pulse choppy pulse

light red tongue

weak pulse

acid reflux and heartburn

early morning awakening

palpitations

thin coating

nausea and vomiting eyes distension lack of interest

irritability

yellow coating dry mouth stuffy chest dizziness depression purple-red tongue

lack of coating

irregular menstruation

foreign object sensation in throat

abdominal bloating

head heaviness

confusion emotional instability

breathlessness

all-night insomnia

running pain in the back, thorax and abdomen

defecation not smooth

gastric discomfort

gastric pain

Figure 6.6. Signs and symptoms associated with the Liver Stagnation pattern The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

The 13 core SSs of the Liver Stag pattern are: 1. wiry pulse (76% sen, 28% spe)

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Treating Insomnia with Chinese Medicine

2. stress and irritability (56% sen, 38% spe) 3. hypochondriac distension (51% sen, 52% spe) 4. lack of appetite (51% sen, 25% spe) 5. stuffy chest (47% sen, 23% spe) 6. agitation (47% sen, 13% spe) 7. frequent dreams (42% sen, 16% spe) 8. hypochondriac pain (40% sen, 59% spe) 9. depression (40% sen, 45% spe) 10. yellow fur (40% sen, 21% spe) 11. red tongue (40% sen, 17% spe) 12. bitter taste in mouth (33% sen, 20% spe) 13. frequent sighs (30% sen, 54% spe). Three SSs had a sensitivity level equal to the thirteenth symptom with a lower specificity level – that is, dry mouth (30% sen, 25% spe), difficulty falling asleep (30% sen, 19% spe) and rapid pulse (30% sen, 13% spe). Nine SSs qualified as high-specificity SSs: 1. 2. 3. 4. 5. 6. 7. 8. 9.

reduced speech (9% sen, 100% spe) bodily pain (7% sen, 100% spe) electric sensation (7% sen, 100% spe) oppressive pain in the back, chest and abdomen (7% sen, 100% spe) running pain in the back, chest and abdomen (7% sen, 100% spe) stabbing pain in the back, chest and abdomen (7% sen, 100% spe) emotion-triggered symptoms (7% sen, 100% spe) distension and pain in the breast (5% sen, 100% spe) hypochondriac running pain (5% sen, 100% spe).

The most common tongue and pulse features for Liver Stag are: 1. 2. 3. 4. 5. 6. 7. 8.

yellow coating (31%, 20%) red tongue (31%, 17%) thin coating (22%, 19%) white coating (22%, 19%) wiry and rapid pulse (20%, 39%) wiry pulse only (16%, 82%) pale tongue (13%, 8%) wiry and thin pulse (11%, 16%)

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

9. greasy coating (11%, 10%) 10. thin, wiry and slippery pulse (4%, 100%) 11. wiry and slippery pulse (4%, 17%) 12. wiry, slippery and rapid pulse (4%, 17%). The most specific features of the Liver Stag pattern are: 1. thin, wiry and slippery pulse (4%, 100%) 2. wiry pulse only (16%, 82%). 2.2.2. Prescriptions for Liver Stag The herbs used to treat Liver Stag are reported in Figure 6.7. heshouwu

huangqin

suanzaoren longchi longgu

gancao

danggui

zhimu

hehuanhua

huangqi

maiya

shengma huanglian

hehuanpi

changpu

renshen wuweizi

fuling

chaihu

chuanxiong chenpi

zhizi

banxia

xiakucao

yuanzhi

fushen meiguihua

xiangfu

baishao

danpi bohe gouqizi

muli

yejiaoteng

cishi

zexie

shengjiang wuzhuyu

zhishi

yujin

maidong longyanrou

dazao

chuanlianzi

baiziren baihe

shengdi

baizhu

zhenzhumu

zhiqiao

Figure 6.7. Herbs used for the Liver Stagnation pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

The nine core herbs of Liver Stag are reported in Table 6.4. Table 6.4. Core herbs of the Liver Stag pattern Herb (sen, spe)

Mean dose (min–max)

Chaihu (99%, 42%)

11.6g (9–20g)

Baishao (99%, 44%)

14.3g (10–20g)

Type

Notes

Raw (2), stir-fried (1)

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Treating Insomnia with Chinese Medicine Herb (sen, spe)

Mean dose (min–max)

Type

Notes

Danggui (70%, 25%)

11.4g (6–20g)

Gancao (61%, 15%)

6.7g (5–10g)

Prepared (7), raw (1)

Fuling (60%, 17%)

14.2g (10–15g)

From Yunnan (1)

Baizhu (51%, 35%)

12.5g (6–20g)

Stir-fried (2), raw (1)

Xiangfu (36%, 62%)

11.1g (9–20g)

Zhizi (36%, 28%)

10.3g (10–12g)

1. Use it stir-fried, and only when the agitation is important (1) 2. It has to be used carefully when the spleen-stomach of the patient is bad (1)

Danpi (35%, 59%)

10.6g (10–12g)

If the case is chronic, use danshen instead of danpi as it has stronger blood-activating effects (1)

It is an important herb for liver stagnation with blood deficiency (1)

For the Liver Stag pattern, the formula is modified according to six types of modification methods (Table 6.5). Table 6.5. Modification methods of the Liver Stag pattern Pattern

Signs and symptoms

Added herbs

Fire (7)

Agitation (6)

Zhizi (5), huanglian (5), huangqin (3)

Spleen deficiency (2)

Lack of appetite (2), abdominal bloating (2)

Baizhu (3), shanzha (2), guya (2)

Anxiety (3), palpitations (3)

Suanzaoren (2), baiziren (2), yejiaoteng (2), cishi (2), hupo (2), zhenzhumu (2)

Stuffy chest (3)

Xiangfu (4), chuanxiong (3)

Stagnation (2)

Changpu (2), dannanxing (2)

Phlegm (2) Constipation (2) with dry stools (2)

Dahuang (2)

2.2.3. Clinical pearls for Liver Stag Recommendations from clinicians regarding the Liver Stag pattern are as follows:

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

1. This type is the most common (1). 2. This type is extremely difficult to treat and it might even be impossible to treat it with medication (1). 3. ‘The patients from this type often take benzodiazepines without success. Some also take antidepressant and anxiolytic drugs such as flupentixol/melitracen, but this does not resolve the problem from the root and can even provoke side effects and severely affect the patient’s work and quality of life.’ 4. ‘In the case of comorbid depression, if the tongue is not red and the fur thin, herbs that have dispersing and warm-unblocking (wentong 温通) effects like mahuang, qianghuo, chuanxiong and guizhi are generally added. They can increase the liver-draining and congestion-eliminating effects of Xiao Yao San and also help the heart yang, disperse the yin haze, make the patient’s mood high during the day and improve the sleep quality during the night.’ 5. ‘[When treating] a liver-fire type insomnia, remember to drain liver stagnation and tonify the liver while you clear liver fire. “In case of excess, drain the child”, you can drain liver fire by clearing heart fire.’ 6. Do not use high doses of oppressing, phlegm-breaking and panic-calming minerals, which are effective in the short term but make the situation worse in the long term (1). 7. When treating liver stagnation, use herbs to regulate the spleen-stomach such as chenpi, fuling, sharen and gancao (3). 8. Adding a few blood-activating herbs at the beginning of qi stagnation can prevent the development of blood stasis (1). 9. Difficulty falling asleep is a condition of ‘yang unable to penetrate the yin’. In this case, the treatment must move inside and downward and not only outside and upward. Chaihu can be replaced by chuanlianzi and high doses of longgu and muli can be used (1). 10. Liver-draining herbs are pungent, warm, fragrant and dry; they can damage the qi and the yin. Do not use too much of them and consider using yin-nurturing herbs (4). 11. Emotional regulation is important for this type. The patient should avoid emotional excitement, regulate one’s emotions and deal with insomnia with a relaxed attitude (1). A 62-year-old female consulted for intermittent insomnia for ten years, aggravated for two months. She reported trouble falling asleep

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Treating Insomnia with Chinese Medicine

and frequent dreams, and had to take one pill of eszopiclone before bedtime to fall asleep. She was agitated and recently had throat pain, sometimes phlegm, abundant sweating, a hot sensation in the head and irritability. Her appetite was good, stools and urine normal. The tongue was light red with teeth marks and a greasy coating. The pulse was wiry. This is a pattern of liver stagnation producing heat. She was prescribed danpi 10g, chao zhizi 10g, danggui 10g, baishao 12g, chaihu 10g, bohe 10g, chao baizhu 20g, fuling 30g, xiakucao 10g, qing banxia 9g, yuanzhi 10g, chao suanzaoren 20g, zhimu 10g and sheng maiya 20g. The patient was asked to gradually reduce the use of eszopiclone. After 12 bags, sleep was significantly improved, she reduced the use of eszopiclone and her mood was better. The treatment was continued.

2.3. Liver Fire 2.3.1. Liver Fire population characteristics and signs/symptoms No associated population or characteristic of the Liver Fire pattern was able to reach the threshold of two citations. A disease of liver heat…manifests with competing heat, raving, panic, hypochondriac distension and pain, agitation of hands and feet, and insomnia. Suwen chapter 32

The SSs indicating Liver Fire are reported in Figure 6.8. The 13 most common SSs of Liver Fire are: 1. bitter taste in mouth (82% sen, 20% spe) 2. dark and scanty urine (77% sen, 42% spe) 3. stress and irritability (77% sen, 21% spe) 4. rapid pulse (77% sen, 13% spe) 5. eye redness (71% sen, 38% spe) 6. yellow fur (71% sen, 15% spe) 7. red tongue (65% sen, 11% spe) 8. wiry pulse (65% sen, 10% spe) 9. agitation (65% sen, 7% spe) 10. constipation (47% sen, 22% spe) 11. dry mouth (47% sen, 15% spe)

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

12. frequent dreams (47% sen, 7% spe) 13. all-night insomnia (41% sen, 25% spe).

agitation constipation

preference for cold drinks

yellow coating thirst headache

hot sensation in thorax

all-night insomnia

sleepwalking

thready pulse

irritability urine dark and scant side distension tinnitus oral ulcer

panic awakening

tongue tip red

dry throat

difficulty falling asleep

red complexion overthinking

stuffy chest thready pulse

bier mouth dizziness frequent panic

side pain

somniloquence

thin coating

dry mouth head confusion nightmares

dry stools

strong pulse

wiry pulse

rapid pulse

lack of appetite

red tongue

painful urination haematuria

frequent dreams palpitations dry tongue

frequent sigh

frequent awakenings

slippery pulse

eyes distension sensibility dry coating

fever irregular menstruation

thorax ache

red eyes

head distension tongue ulcer

Figure 6.8. Signs and symptoms associated with the Liver Fire pattern The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

Two SSs had the same sensitivity level as the thirteenth symptom but a lower specificity level – tinnitus (41% sen, 20% spe) and dizziness (41% sen, 18% spe). No high-specificity SS was identified for Liver Fire. The most common tongue and pulse features of the Liver Fire pattern are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

yellow coating (60%, 14%) red tongue (55%, 11%) wiry and rapid pulse (45%, 32%) red tip of tongue (15%, 38%) strong and rapid pulse (10%, 67%) dry coating (10%, 67%) wiry, slippery and rapid pulse (10%, 17%) thin coating (10%, 3%) thin and rapid pulse (5%, 5%).

There are no specific features for the Liver Fire pattern.

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2.3.2. Prescriptions for THE Liver Fire pattern The herbs used for Liver Fire are shown in Figure 6.9. hehuanpi

mutong

danzhuye

danpi

shengdi gancao huangqin longdancao xiakucao

zexie

chaihu danggui cishi

shijueming

suanzaoren

daizheshi

yujin lianqiao

huanglian

muli fuling

hehuanhua

longgu

baishao

zhizi

zhenzhumu

cheqianzi zhusha

yejiaoteng

fushen

longchi

xiangfu

Figure 6.9. Herbs used for the Liver Fire pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

The ten core herbs of the Liver Fire pattern are reported in Table 6.6. Table 6.6. Core herbs of the Liver Fire pattern Herb (sen, spe)

Type

Zhizi (100%, 35%)

Raw (2)

Huangqin (100%, 27%)

Stir-fried (1)

Shengdi (100%, 27%) Longdancao (90%, 95%) Danggui (90%, 13%) Cheqianzi (80%, 100%) Chaihu (80%, 13%) Gancao (70%, 6%) Zexie (65%, 52%) Mutong (60%, 92%) No description of the dose and no notes were available in the CERs.

Four types of modification methods were identified for Liver Fire (Table 6.7).

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Table 6.7. Modification methods of the Liver Fire pattern Pattern

Signs and symptoms

Added herbs

Stuffy chest (3), hypochondriac distension (3), frequent sighs (2)

Yujin (3), chaihu (2), foshou (2)

Severe insomnia (2)

Longgu (3), muli (3)

Constipation (2)

Dahuang (2)

Dizziness (2) and headaches (2)

Cishi (2)

2.3.3. Clinical pearls for Liver Fire Recommendations from clinicians regarding the Liver Fire pattern are as follows: 1. This pattern is often due to an emotional explosion caused by long-term emotional oppression. 2. ‘In this formula [Long Dan Xie Gan Tang], danggui and shengdi, which augment the yin, nurture the blood and harmonize the liver, are combined with a large group of clearing and eliminating herbs in order to tonify within the elimination, nurture within the draining, prevent the fire-clearing herbs from damaging the yin with their bitterness-dryness, and remove the evil without damaging the regular.’ 3. Do not use cold fire-draining formulas, which would create stagnation and increase the fire. A 45-year-old female consulted in October 2016 for insomnia and frequent dreams for three months. She presented with agitation, bad sleep quality, trouble falling asleep and frequent dreams. She was generally irritable and had a dry mouth, a bitter taste in her mouth, tension and pain in the chest and sides. Her urine was dark and stools dry. Her complexion was red, her tongue red, her pulse wiry and rapid. This is a pattern of liver fire disturbing the heart. She was prescribed Long Dan Xie Gan Tang: longdancao 12g, chaihu 10g, zhizi 10g, huangqin 10g, danggui 9g, mutong 6g, zexie 15g, cheqianzi 15g (enveloped), shengdi 15g, longchi 30g (cooked longer), muli 30g (cooked longer), dahuang 12g (added at the end), gancao 6g. After 11 bags she was cured.

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2.4. Phlegm-Heat 2.4.1. Phlegm-Heat population characteristics and signs/symptoms The populations associated with Phlegm-Heat are obese people (3) and older adults (2). Common comorbidities are hyperlipidaemia (2), hyperviscosity syndrome (2) and depression (3). In most cases, insomnia is caused by fire burning and phlegm stagnation due to excessive preoccupation. Gujin Yitong Daquan

The SSs indicating Phlegm-Heat are shown in Figure 6.10. The 12 core SSs of Phlegm-Heat are: 1. slimy fur (74% sen, 74% spe) 2. slippery pulse (69% sen, 65% spe) 3. stuffy chest (64% sen, 42% spe) 4. agitation (62% sen, 23% spe) 5. yellow fur (55% sen, 39% spe) 6. nausea and vomiting (52% sen, 77% spe) 7. rapid pulse (52% sen, 30% spe) 8. red tongue (50% sen, 28% spe) 9. bitter taste in mouth (48% sen, 41% spe) 10. head heaviness (38% sen, 88% spe) 11. belching (36% sen, 58% spe) 12. abundant phlegm (33% sen, 95% spe). Two high-specificity SSs have been identified: 1. aversion to food (9% sen, 100% spe) 2. sticky sensation in mouth (9% sen, 100% spe). The most common tongue and pulse features of the Phlegm-Heat pattern are: 1. greasy coating (57%, 74%) 2. yellow coating (43%, 39%)

84

weak pulse

abnormal dreams

fatigue

wiry pulse dull complexion

side distension

large tongue

dry mouth without thirst preference for cold drinks

red complexion mess (zaoza)

rapid pulse

fatigue at rising lack of interest

indented tongue dark red tongue dry coating deep pulse suspicion

body heaviness

blocked throat

early morning awakening

gastric bloating

confusion

watery coating

dry eyes

headache

lack of aention

red tongue lack of appetite

overthinking blocked breathing

palpitations

sleepiness

bad breath

constipation

relaxed pulse

dry stools

side pain

borborygmi

abdominal bloating

frequent dreams acid reflux and heartburn

dry lips

nausea and vomiting yellow coating

dry throat

slowness

light sleep

thready pulse

sticky mouth

panic awakening

The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

Figure 6.10. Signs and symptoms associated with the Phlegm-Heat pattern

anxiety

snoring fever

vertigo head heaviness

moist pulse depression

thick coating

hiccup

frequent sigh aversion to food dizziness phlegm

slippery pulse white coating bier mouth

forgetfulness

phlegm whistling

stuffydifficulty chest falling asleep

eructation

thin coating

agitation

greasy coating frequent panic

nightmares abdominal pain mental retardation

defecation not smooth

pale tongue

frequent awakenings

thirst dry mouth putrid eructation yellow complexion tinnitus stool with rancid smell full pulse all-night insomnia diarrhoea

gastric pain

cough

urine dark and scant

strong pulse

abundant phlegm irritability

red eyes

Treating Insomnia with Chinese Medicine

3. red tongue (39%, 8%) 4. slippery and rapid pulse (29%, 96%) 5. white coating (15%, 18%) 6. pale tongue (13%, 11%) 7. thick coating (9%, 64%) 8. slippery pulse only (8%, 55%) 9. wiry and slippery pulse (8%, 50%) 10. wiry, slippery and rapid pulse (7%, 42%) 11. weak and thin pulse (4%, 8%). The most specific tongue and pulse features of the Phlegm-Heat pattern are: 1. 2. 3. 4. 5. 6.

relaxed and humid pulse (3%, 100%) relaxed pulse only (1%, 100%) strong pulse only (1%, 100%) replete pulse only (1%, 100%) slippery and rapid pulse (29%, 96%) greasy coating (57%, 74%).

When the pulse of an insomnia patient is slippery, rapid and strong, there is stagnation of phlegm and fire in the centre. This is insomnia due to stomach disharmony. Zhangshi Yitong

2.4.2. Prescriptions for Phlegm-Heat The herbs used for Phlegm-Heat are reported in Figure 6.11. The nine core herbs of the Phlegm-Heat pattern are reported in Table 6.8. Table 6.8. Core herbs of the Phlegm-Heat pattern Herb (sen, spe)

Mean dose (min–max)

Chenpi (98%, 79%)

11.6g (9–15g)

Banxia (97%, 72%)

12.2g (8–30g)

Type

Notes

Fa (6), Qing (4), Jiang (1)

Use high doses (3), usually 12–15g (1), 15–20g (1) or 20–30g (1)

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine Fuling (93%, 36%)

16.0g (9–45g)

Red (1), from Yunnan (2)

Zhishi (84%, 88%)

10.7g (6–15g)

Stir-fried (2)

Zhuru (75%, 98%)

11.3g (6–15g)

Gancao (68%, 21%)

6.3g (3–10g)

Prepared (7), raw (2)

Huanglian (43%, 40%)

9.6g (5–15g)

From Sichuan (1)

Yuanzhi (21%, 18%)

10.1g (6–15g)

Prepared (1)

Changpu (20%, 42%)

13.4g (9–20g)

huanglian

Use high doses, usually 20–30g (1)

fuling

tianzhuhuang

yuanzhi baizhuhuangqin

tinglizi gualou

zhebeimu

laifuzi

chenpi zhuru yejiaoteng

chuanxiong huomaren muxiang

longgu

dangshen

muli

maiya

cishi

renshen

wuweizi

houpo

shengjiang hehuanpi

chaihu qingpi cangzhu

jineijin dandouchi

suanzaoren dannanxing shanzha dazao changpu zhenzhumu

chuanlianzi fushen juhong xiakucao xiangfu baiziren

lianqiaozhiqiao danpi

zhishi hupo

banxia gancao

shenqu

longchi

yujin shudihuang

zhizi shumi

zhimu lianzixin

nanxing

Figure 6.11. Herbs used for the Phlegm-Heat pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

The following methods of modification have been identified for the Phlegm-Heat pattern (Table 6.9). Table 6.9. Modification methods of the Phlegm-Heat pattern Pattern

Signs and symptoms

Added herbs

Fire (10)

Agitation (4), bitter taste in mouth (3), tip of the tongue red (2), hot chest (2), dry mouth (2)

Huanglian (12), zhizi (10), dandouchi (3), huangqin (3)

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Treating Insomnia with Chinese Medicine Pattern

Signs and symptoms

Added herbs

 

Severe insomnia (3), persistent insomnia (2), depression (2), anxiety (2), frequent panic (2), frequent dreams (2)

Longgu (4), muli (4), suanzaoren (4), zhenzhumu (3)

 

Constipation (8)

Dahuang (8)

Food stagnation (4)

Abdominal distension (3), stomach distension (2), lack of appetite (2), putrid belching (2), acid reflux (2)

Shenqu (5), shanzha (5), laifuzi (4), maiya (3)

Phlegm-heat (5)

 

Huanglian (2), tianzhuhuang (2)

 

Hypochondriac distension (2), stuffy chest (2), bitter taste in mouth (2)

Chaihu (3), huangqin (2), chuanlianzi (2), yujin (2)

Qi deficiency (2)

Fatigue (2)

Huangqi (3)

Dampness

 

Huoxiang (2), peilan (2)

2.4.3. Clinical pearls for Phlegm-Heat Recommendations from clinicians regarding Phlegm-Heat are as follows: 1. ‘This type is frequently observed in the clinic.’ 2. Relatively easy to treat if the diagnosis is precise (1). 3. You can diagnose this pattern just on the basis of ‘slimy fur’; there is no need to have other indications (1). 4. A yellow and slimy fur is crucial to diagnose phlegm-heat. As patients may present diverse clinical manifestations, do not tonify if the patient presents a yellow and slimy fur (1). 5. You can diagnose Phlegm-Heat just on the basis of ‘a restless night, a slimy and yellow fur and a slippery pulse’. 6. ‘The patient usually presents with frequent dreams involving complex situations. The dreams follow one another and there can be work, a conversation, quarrel, brawl with someone else or seeing someone working, fighting or showing bizarre behaviour. After waking up, the dreams are vivid and remembered clearly. This formula is particularly efficient for this type of insomnia.’ 7. ‘In this [pattern], the phlegm is an insubstantial phlegm, it can confuse the heart-orifice, obstruct the heart-spirit and also

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Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine

cover the clear orifice and damage the original spirit, influence the normal consciousness and mental activity, resulting in an aggravation of the insomnia. This makes the disease persistent and the treatment difficult.’ 8. ‘Always add spleen-reinforcing and stomach-harmonizing herbs in case of phlegm-dampness in order to eliminate the source of the disease.’ 9. Zhi yuanzhi and changpu can be used in prevention of this pattern (1). 10. The patient should avoid high-fat food (3), sweet food (1), savoury food (1), spicy food (1), high-salt food (1) and stimulant food (1), and should exercise more (2). 11. In the case of constipation, the whole body is blocked. Therefore, the doctor should pay attention to the situation of defecation (1). 12. ‘As herbs like suanzaoren and wuweizi have a sour-collecting nature, which is not beneficial to phlegm transformation and heat clearing, they must be used in small quantities or not used at all.’ A 47-year-old male consulted in April 2016 for insomnia for more than one month. He had started to experience bad sleep and frequent nightmares without apparent reason. He was diagnosed with insomnia and was prescribed alprazolam. At first the symptoms improved but recently the drug had ceased to be effective. The patient presented with bad sleep quality, nightmares with awakenings in panic and trouble falling asleep, sleeping on average three hours per night; he had low energy in the morning, episodes of dizziness, no significant headaches, a depressed mood, distension in the chest and stomach, and nausea and vomiting. He usually had a good appetite and a preference for fat, sweet and tasty food. His urine was dark and stools dry, evacuating once every 2–3 days. The tongue was red, the coating yellow and slightly greasy, and the pulse slippery. He was prescribed Huang Lian Wen Dan Tang: chuan huanglian 6g, fa banxia 10g, zhuru 15g, zhishi 10g, juhong 10g, fuling 15g, fushen 15g, yejiaoteng 15g, yuanzhi 10g, baiziren 10g, baihe 10g, dahuang 5g, gancao 6g. After 14 bags his sleep was significantly improved and he no longer had nightmares.

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2.5. Blood Stasis 2.5.1. Blood Stasis population characteristics and signs/symptoms The Blood Stasis pattern is associated with long-term insomnia (4) and treatment-resistant insomnia (4). The SSs indicating the Blood Stasis pattern are shown in Figure 6.12. tongue side dark

frequent sigh

anxiety

movement difficulty

depression

black complexion lower belly needling pain

purple tongue choppy pulse head needling pain deep pulse red lines on face

limb numbness speech difficulty dark red tongue dry mouth without thirst

frequent dreams wiry pulse palpitations stuffy chest

side pain

vertigo tight pulse irritability purple lips head confusion

emotional indifference

difficulty falling asleep

forgetfulness

slippery pulse

frequent panic

vexation

red tongue absence of coating black eyes head distension petechia on tongue tip rapid pulse

petechia on tongue

ache agitation thorax needling pain in the thorax blocked menstruation

breathlessness insomnia lack of appetite distension all-night headache sidefatigue congested vessels under tongue

dull complexion

frequent awakenings side needling pain

lower belly ache

cracked skin

overthinking

thready pulse nightmares no sleepiness

panic awakening

irregular menstruation amenorrhoea suffering eructation

black spot on the sclera

Figure 6.12. Signs and symptoms associated with the Blood Stasis pattern The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

When there is a long-term disease and the treatments are ineffective, one must regulate the blood. Puji Fang

The 11 most common SSs for Blood Stasis are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

rough pulse (81% sen, 90% spe) purple tongue (71% sen, 83% spe) wiry pulse (62% sen, 11% spe) agitation (62% sen, 8% spe) petechiae on the tongue (48% sen, 91% spe) headaches (38% sen, 35% spe) stuffy chest (38% sen, 9% spe) frequent dreams (38% sen, 7% spe) difficulty falling asleep (33% sen, 10% spe)

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10. chest pain (29% sen, 50% spe) 11. irregular periods (29% sen, 46% spe). Two SSs – hypochondriac pain (29% sen, 21% spe) and hypochondriac distension (29% sen, 14% spe) – had a sensitivity level equal to the last symptom but a lower specificity level. Seven SSs qualified for high-specificity SSs: 1. 2. 3. 4. 5. 6. 7.

tight pulse (10% sen, 100% spe) stabbing pain in chest (10% sen, 100% spe) hypochondriac stabbing pain (10% sen, 100% spe) absence of sleepiness (10% sen, 100% spe) suffering (10% sen, 100% spe) purple lips (10% sen, 100% spe) cracked skin (10% sen, 100% spe).

The most common tongue and pulse features for the Blood Stasis pattern are: 1. purple tongue (58%, 83%) 2. petechiae on the tongue (38%, 91%) 3. wiry and choppy pulse (38%, 91%) 4. choppy pulse only (19%, 83%) 5. congested vessels under the tongue (12%, 75%) 6. heavy pulse only (8%, 67%) 7. wiry and thin pulse (8%, 5%) 8. heavy and wiry pulse (4%, 33%) 9. slippery pulse only (4%, 9%) 10. wiry pulse only (4%, 9%) 11. heavy and thin pulse (4%, 8%) 12. wiry and slippery pulse (4%, 8%) 13. slippery and rapid pulse (4%, 4%). The most specific tongue and pulse features of the Blood Stasis pattern are: 1. petechiae at the tip of the tongue (4%, 100%) 2. side of the tongue dark (4%, 100%) 3. petechiae on the tongue (38%, 91%)

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4. 5. 6. 7.

wiry and choppy (38%, 91%) purple tongue (58%, 83%) choppy only (19%, 83%) congested vessels under the tongue (12%, 75%).

2.5.2. Prescriptions for Blood Stasis The herbs used in the Blood Stasis pattern are reported in Figure 6.13.

danggui niuxi jiegeng chishao chuanxiong chaihu gancao suanzaoren zhiqiao taoren kushen

hehuanpi

yujin

xiangfu

yejiaoteng

zhenzhumu

cishi

zhishi

zhusha

shenqu

hupo

danshen changpu

baishao

baiziren

longchi

honghua shengdi

huangqi

fuxiaomai

Figure 6.13. Herbs used for the Blood Stasis pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

This formula [Xue Fu Zhu Yu Tang] is miraculous when there is insomnia and the shen-calming blood-nurturing herbs are not effective. Xuezheng Lun

The 12 core herbs of the Blood Stasis pattern are reported in Table 6.10. Table 6.10. Core herbs of the Blood Stasis pattern Herb (sen, spe)

Mean dose (min–max)

Taoren (100%, 96%)

11.1g (9–15g)

Niuxi (96%, 100%)

11.2g (5–15g)

Jiegeng (96%, 100%)

8.4g (4.5–12g)

Chishao (96%, 96%)

11.0g (6–15g)

Danggui (96%, 17%)

12.1g (9–15g)

Chuanxiong (92%, 29%)

10.1g (4.5–15g)

92

Type

Huai (3), Chuan (2)

Roasted in ashes (1)

Pattern-Based Treatment of Insomnia with Chinese Herbal Medicine Chaihu (92%, 19%)

9.7g (3–15g)

Honghua (89%, 96%)

10.4g (6–15g)

Zhiqiao (89%, 52%)

9.9g (6–15g)

Shengdi (85%, 30%)

12.0g (9–15g)

Gancao (81%, 9%)

7.0g (3–10g)

Raw (3), prepared (2)

Suanzaoren (31%, 6%)

23.8g (15–30g)

Stir-fried (1)

Stir-fried (1)

There were no notes associated with the core herbs.

The formulas of the Blood Stasis pattern are modified according to two situations (Table 6.11). Table 6.11. Modification methods of the Blood Stasis pattern Pattern

Signs and symptoms

Added herbs

Qi stagnation (2)

 

Xiangfu (2), chuanlianzi (2)

Liver (2) fire (3)

 

Zhizi (3), huangqin (2)

2.5.3. Clinical pearls for Blood Stasis Recommendations from clinicians regarding Blood Stasis are as follows: 1. ‘Persistent diseases are often managed from a blood stasis perspective.’ 2. ‘Blood-stasis-induced insomnia is not commonly observed in the clinic.’ 3. Blood-nurturing and blood-harmonizing herbs should be used in order to avoid harming the blood. You can also add blood-cooling herbs to address the stasis-heat (1). 4. Because this is a long-term condition, do not use strong decoctions but use pills to exhaust the problem slowly (1). A 42-year-old male consulted for persistent insomnia for more than two years. He had severe difficulties getting to sleep, had frequent dreams as soon as he fell asleep, was depressed, had dizziness and headaches, his complexion was black, he had pityriasis versicolor on the back and chest, the skin of his lower limbs was cracked, his tongue was purple with a yellow greasy coating, and his pulse was thin and wiry. He was prescribed: chaihu 9g, shengdi 15g, danggui 9g,

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chuanxiong 15g, honghua 9g, taoren 9g, zhiqiao 5g, jiegeng 5g, niuxi 5g, cizhuwan 9g (enveloped), sheng gancao 3g. After two bags his mood was improved and he could sleep better. After seven more bags the dizziness and headaches were significantly reduced and he could sleep five hours per night.

2.6. Heart-Spleen Deficiency 2.6.1. H-S Def population characteristics and signs/symptoms H-S Def is commonly seen in women (2), older adults (2), patients with a weak constitution (2) and overthinking people (2). When insomnia patients do not have evils, there is always a lack of nutritive and blood. The nutritive governs blood, when the blood is deficient it cannot nurture the heart, when the heart is deficient the spirit cannot stay at home. Jingyue Quanshu

The SSs indicating H-S Def are reported in Figure 6.14.

forgetfulness

nausea and vomiting

hot sensation in thorax

light-coloured menstruation

lack of appetite dull complexion gastric bloating

hands and feet hot anxiety lack of coating purpura light red tongue

thin coating fatiguefrequent awakenings agitation

stuffy chest red tongue

thorax ache

white coating

breathlessness diarrhoea

rapid pulse pale complexion

irregular stools urine light and abundant excessive menstruation

frequent dreams difficulty falling asleep

tongue vertigoindented panic awakening

palpitations thinness

thready pulse high-pitched voice

tinnitus

night sweat moist pulse

frequent panic

deep pulse

wiry pulse

yellow complexion

lack of taste large tongue abdominal bloating

fever

sore muscles

tender tongue

relaxed pulse

aversion to speech

weak pulse

pale tongue

dizziness

gastric bloating aer eating

spontaneous sweat

Figure 6.14. Signs and symptoms associated with the Heart-Spleen Deficiency pattern The font is darker for SSs with a high specificity level and bigger for SSs with a high sensitivity level.

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The 12 most commonly reported SSs for H-S Def are: 1. fatigue (94% sen, 42% spe) 2. palpitations (92% sen, 36% spe) 3. pale tongue (83% sen, 34% spe) 4. fine pulse (81% sen, 25% spe) 5. weak pulse (75% sen, 60% spe) 6. forgetfulness (72% sen, 49% spe) 7. lack of appetite (72% sen, 29% spe) 8. frequent dreams (69% sen, 22% spe) 9. thin fur (64% sen, 36% spe) 10. dull complexion (61% sen, 51% spe) 11. frequent awakenings (56% sen, 34% spe) 12. white fur (47% sen, 27% spe). The only high-specificity symptom is ‘stomach bloating after eating’ (6% sen, 100% spe). The most common tongue and pulse features of H-S Def are: 1. 2. 3. 4. 5. 6. 7.

pale tongue (67%, 34%) weak and thin pulse (53%, 63%) thin coating (51%, 36%) white coating (38%, 27%) teeth marks (11%, 25%) wiry and thin pulse (7%, 8%) relaxed and weak pulse (4%, 50%).

There are no specific tongue and pulse features for the H-S Def pattern. 2.6.2. Prescriptions for H-S Def The herbs used for H-S Def are reported in Figure 6.15.

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fushen longyanrou muxiang shengjiang baiziren

chaihu

dangguiyuanzhi baishao

baihe longchi

yejiaoteng zhenzhumu

zhimu

sharen

shanyao

baizhu gancao

muli

hehuanpi

cishi

kushen

wuweizi

heshouwu danshen

shudihuang shenqu

suanzaorenfuling dazao chenpi

changpu

dangshenhuangqi renshen banxia

hehuanhua

chuanxiong

Figure 6.15. Herbs used for the Heart-Spleen Deficiency pattern The font is darker for herbs with a high specificity level and bigger for herbs with a high sensitivity level.

The 11 core herbs of H-S Def are reported in Table 6.12. Table 6.12. Core herbs of the Heart-Spleen Deficiency pattern Herb (sen, spe)

Mean dose (min–max)

Type

Baizhu (95%, 51%)

12.8g (9–15g)

Stir-fried (4)

Huangqi (96%, 84%)

23.5g (12–30g)

Yuanzhi (96%, 48%)

11.3g (4–15g)

Prepared (2)

Suanzaoren (93%, 30%)

22.4g (12–40g)

Stir-fried (5)

Gancao (91%, 17%)

7.6g (6–10g)

Prepared (16)

Danggui (87%, 27%)

12.0g (10–15g)

Muxiang (76%, 94%)

9.1g (6–10g)

Longyanrou (73%, 94%)

11.5g (9–20g)

Fushen (64%, 60%)

11.8g (10–15g)

Dangshen (49%, 52%)

15.2g (10–20g)

Renshen (49%, 42%)

15.0g (15–15g)

Notes

Guang (1)

A good herb to reinforce the spleen and appease the thoughts (1) Chao (1)

Three types of modification methods have been identified for the H-S Def pattern (Table 6.13).

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Table 6.13. Modification methods for the Heart-Spleen Deficiency pattern Pattern

Signs and symptoms

Added herbs

Spleen deficiency (6) and dampness (2)

Stomach distension (6), lack of appetite (7), slimy fur (7)

Banxia (8), chenpi (6), fuling (3), houpo (3)

 

Severe insomnia (5)

Longgu (5), muli (4), baiziren (3), wuweizi (3)

Blood deficiency (4)

 

Shudi (4), ejiao (4)

2.6.3. Clinical pearls for H-S Def The recommendations of clinicians regarding H-S Def are as follows: 1. This type is relatively easy to treat if the diagnosis is precise (1). 2. ‘In general people are sleepier and fall asleep more easily after being active, patients with this type of insomnia – heart-spleen qi-blood deficiency – usually have more difficulty sleeping after being active, they have persistent palpitations and cannot have a calm sleep.’ 3. The root of the qi and blood deficiency – such as bleeding, spleen deficiency with diarrhoea or chronic atrophic gastritis – has to be treated first (1). 4. ‘Use heavy-sedative (zhongzhen 重镇) herbs like daizheshi and zhenzhumu carefully in order to prevent spleen-stomach damage.’ A female patient consulted for bad sleep quality for six months. Due to work stress, the patient started to experience trouble falling asleep, frequent dreams, early-morning awakenings, agitation, irritability, frequent sighing, dizziness, lack of appetite and fatigue. Stools and urine were normal. The tongue was pale with teeth marks and thin coating; the pulse was thin and weak. The patient was prescribed Gui Pi Tang: dangshen 12g, chao suanzaoren 15g, fuling 15g, huangqi 15g, chao baizhu 12g, chao maiya 15g, danggui 15g, danshen 12g, yuanzhi 10g, hehuanhu 15g, hehuanpi 15g, yujin 10g, chenpi 10g, muxiang 6g. After four bags the patient experienced improvement. After 18 bags all the symptoms were significantly reduced. She was discharged from hospital and asked to take Gui Pi pills to consolidate the efficacy. At a follow-up two months later, she reported that her sleep was almost normal and her mood had improved.

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3. Interpretation and discussion 3.1. Pathological systems Three pathological systems composed of causes and mechanisms that are closely associated with one another have been identified. These systems, which are relatively independent from one another, are the liver stagnation system, the yin deficiency and fire system, and the heart and spleen deficiency system. 3.1.1. Liver stagnation system The liver stagnation system has a core composed of the Liver Stagnation, Liver Fire and Classical Formulas patterns and two branches – Phlegm-Heat and Blood Stasis. The three core patterns share common ingredients (e.g. chaihu, huangqin, baishao) and also common SSs (e.g. wiry pulse, stress and irritability, frequent dreams). Excessive emotions, which can provoke stagnation and fire, are the main pathological cause of this system. Stagnating fire is a common feature of these three patterns, and it is understood by clinicians across patterns that stagnating fire has to be treated with both clearing and dispersing herbs. Nevertheless, this feature is particularly significant in the Liver Fire pattern, for which a bitter taste in the mouth, dark and scanty urine, rapid pulse and yellow coating are major SSs. The core herbs of Liver Fire are mainly cold herbs such as huangqin, shengdi and zhizi. Liver Stagnation and Liver-Spleen Disharmony (i.e. Classical Formulas) are literally twin patterns. Liver stagnation and spleen deficiency are the main features of both patterns. The reasons for the two being separated during the cluster analysis is that they differ in terms of the herbs used. Liver-Spleen Disharmony is almost exclusively composed of classical formulas, in which dazao, shengjiang and gancao are widely used. Some may argue that these herbs have a limited role in the formula and do not represent its direction. However, dazao, shengjiang and gancao may represent a basic feature of the treatment of diseases by Zhang Zhongjing – that is, the regulation of the spleen-stomach with sweet and neutral or warm herbs. Therefore, there is some logic in clustering chaihu-type formulas, guizhi-type formulas and Ban Xia Xie Xin Tang. Besides the use of dazao, shenjiang and gancao, the main difference between Liver Stag and Liver-Spleen Disharmony is the tendency toward blood deficiency of Liver Stag and the tendency toward yang deficiency of L-S Dis. For example, danggui and baishao are core herbs for Liver

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Stag, which is associated with middle-aged females, while guizhi is a core herb of Liver-Spleen Disharmony, for which yang deficiency is a main modification situation. Although both are associated with mood disorders, there is a tendency towards psychosomatic symptoms such as running pain and electric sensations in the body for Liver Stag and a tendency toward physical conditions and symptoms such as fatigue and throat pain, as well as psychosis (which is a major indication of Chai Hu Jia Long Gu Mu Li Tang in the Shanghan Lun), for Liver-Spleen Disharmony. Emotion-induced liver stagnation is the first step of the liver stagnation system, which evolves gradually toward phlegm and blood stasis. Unsurprisingly, Liver Stag is associated with acute insomnia, while Phlegm-Heat and Blood Stasis are associated with persistent insomnia. Phlegm-Heat differs from the rest of the system because of its association with spleen-stomach. Indeed, the main cause of Phlegm-Heat is excessive consumption of sweet and greasy food, which can cause phlegm-heat through food stagnation and/or spleen deficiency. Nausea/ vomiting and belching are common SSs of Phlegm-Heat. Phlegm-Heat is also associated with metabolic disorders such as obesity and hyperlipidaemia. Unblocking the intestinal tract is crucial for this pattern, as we can see by the importance of dahuang in the modification methods and as stated by one clinician. A slimy fur (and the related sticky sensation in the mouth) is a strong indicator of Phlegm-Heat, as shown in the high specificity of this sign and as stated by three clinicians. Compared with Liver Stag, Yin-Def-Fire and Phlegm-Heat, Blood Stasis is relatively uncommon. Blood Stasis is strongly associated with persistent and treatment-resistant insomnia. This pattern is almost exclusively associated with Xue Fu Zhu Yu Tang. A rough pulse and purple tongue are common and highly specific signs of this pattern. 3.1.2. Yin deficiency and fire system The Yin-Def-Fire pattern is by far the most common pattern of insomnia, yet also one of the most heterogeneous. This pattern is composed of two main mechanisms – kidney yin deficiency and heart fire – and can be divided in sub-patterns according to the ratio of yin deficiency and fire, with formulas such as Zhi Zi Chi Tang on the fire end, formulas such as Liu Wei Di Huang Wan on the yin deficiency end, and formulas such as Huang Lian E Jiao Tang, Suan Zao Ren Tang and Zhu Sha An Shen Wan in the middle.

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The presence of kidney-yang-tonic formulas such as Shen Qi Wan and Er Xian Tang and the common combination of Jiao Tai Wan and Huang Lian E Jiao Tang show that there is no strict delimitation between kidney yin and kidney yang deficiency. Kidney yin deficiency and kidney yang deficiency can aggravate each other and both can provoke the surge of deficient fire. The yin deficiency and fire system differs from the liver stagnation system in terms of pathological mechanism and population. The liver stagnation system is mainly caused by excessive emotions touching a relatively young and healthy population, whereas the yin deficiency and fire system is mainly based on constitutional causes such as weak constitution, chronic diseases and aging, affecting a relatively old and unhealthy population. However, some connections exist between the two systems through liver blood deficiency and heart-liver fire. 3.1.3. Heart and spleen deficiency system The H-S Def pattern is relatively isolated from the other pathological systems of insomnia. H-S Def has unique features: it is the only pure deficient pattern; it is caused by overstrain (including working and thinking too much); the insomnia is aggravated by activity (in the other patterns, sleep improves with activity); it is the only pattern for which agitation is not one of the main SSs. H-S Def has a relatively strong connection with spleen deficiency, which is one of the main causes of the pattern. Some of the core herbs of this pattern are spleen-regulating herbs such as baizhu, muxiang and fushen. Regulating the spleen is the most common modification method. The use of heavy-sedative herbs should be limited as these herbs can harm the spleen-stomach. Spleen deficiency is also the (thin) point of connection of this pattern with other patterns such as L-S Dis, Liver Stag and Phlegm-Heat.

3.2. Characteristics of typical patterns As we can see in Table 6.1, patterns vary greatly in terms of acceptance, heterogeneity and specificity. The Yin-Def-Fire pattern, the Class For pattern and the Phlegm-Heat pattern, which respectively account for 23%, 20% and 19% of the patterns of insomnia, are widely accepted by the community of clinicians. In comparison, Liver Fire and Blood Stasis, which respectively account for 5% and 7% of the formulas, are much less widely accepted. To a certain 100

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extent, this represents how frequently these patterns present in the insomnia population, with yin deficiency and phlegm-heat being much more common than blood stasis and liver fire. Liver stagnation is also a frequent pattern, especially if we combine Liver Stag with Liver-Spleen Disharmony (i.e. Classical Formulas). Although Gui Pi Tang is the most popular formula for insomnia, we can see that H-S Def actually accounts for only 12% of the formulas for insomnia, and therefore may not be frequently observed in the clinic. The Yin-Def-Fire pattern shows a high heterogeneity and was easily broken into sub-categories depending on the variables of the cluster analysis. This shows how Yin-Def-Fire is a combination of highly related sub-patterns such as kidney yin deficiency, kidney yang deficiency, liver blood deficiency, liver and heart fire, etc. Due to the high heterogeneity of the Classical Formulas pattern, we decided to present it as individual formulas instead of a unified pattern. However, the combination of varied formulas such as Chai Hu Jia Long Gu Mu Li Tang, Gui Zhi Tang, Gan Mai Da Zao Tang and Ban Xia Xie Xin Tang in a single cluster reflects the close integration of mechanisms such as liver qi stagnation, spleen deficiency, blood deficiency, impaired yangqi movements and middle jiao disharmony. It also reflects the patterns in the composition of classical formulas, in which ingredients such as shengjiang, dazao and gancao are widely used. The heterogeneity of a pattern can guide clinical decisions. For example, when facing a patient with signs of yin deficiency and fire, the clinician can choose from among several formulas, possibly combine different formulas from this pattern or even design his own formula. However, facing a patient with signs of qi and blood deficiency, the clinician can be confident in prescribing Gui Pi Tang as there is little (and possibly no need for an) alternative. Liver Stag, Liver Fire, Class For and to a certain extent Yin-Def-Fire show a low specificity in terms of herbs and SSs. This reflects how liver qi stagnation and, to a certain extent, heat-fire and yin deficiency are core mechanisms of insomnia, which is in line with the use of Suan Zao Ren Tang and liver-soothing formulas such as Xiao Chai Hu Tang and Xiao Yao San on a disease basis (i.e. regardless of the SSs of the patient) for insomnia. On the other hand, Phlegm-Heat, Blood Stasis and H-S Def are relatively isolated from this core mechanism. Specificity can be considered in making clinical decisions. For example, H-S Def is relatively easy to distinguish from other types of insomnia and the prescription should be relatively simple, whereas the Liver Stag pattern

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is harder to distinguish from related core patterns such as Liver-Spleen Disharmony (i.e. Classical Formulas), Liver Fire and Yin-Def-Fire, and the prescription might be a combination of different formulas and individual herbs addressing different aspects of the pathological mechanism.

3.3. Comparison with current pattern classifications The present classification system presents many similarities with current pattern classifications from textbooks and clinical guidelines. Yin Deficiency and Fire, Phlegm-Heat and Heart and Spleen Deficiency are widely recognized as the main patterns of insomnia. Wen Dan Tang, Gui Pi Tang and Long Dan Xie Gan Tang are also widely recognized as the main formulas for insomnia. However, some discrepancies exist between our classification and the current official position. First, various patterns such as Kidney Yin Deficiency, Heart Yin Deficiency, Heart Fire, Yin Deficiency with Fire and Non-Communication between Heart and Kidney are grouped under one single category in our classification. Second, in our classification Liver Stagnation is considered as a major and also a key pattern in the pathological model of insomnia, whereas it is rarely put forward in current classifications without ‘Transforming into Fire’. The reason might be that Liver Stagnation does not explain directly how insomnia is generated in a conventional way (i.e. the heartspirit is neither disturbed nor is there lack of nutrition). This could be a difference between a conceptual approach and a clinical approach of the classification of insomnia patterns. Third, the Heart and Gallbladder Qi Deficiency pattern is absent from our classification. Although An Shen Ding Zhi Wan is one of the most common formulas for insomnia in our classification, it was classified into different categories depending on the variables of the cluster analysis. In no case was it able to create a cluster by itself or lead other formulas to create a cluster. It means that An Shen Ding Zhi Wan lacks a clear direction in terms of composition compared with other formulas such as Wen Dan Tang, Gui Pi Tang or Xue Fu Zhu Yu Tang which can be identified by specific phlegm-transforming, tonifying and blood-moving herbs, respectively. Fourth, Food Stagnation is absent from our classification. Bao He Wan is proposed by many clinicians for the treatment of insomnia, but this formula does not create or lead a cluster no matter how the cluster analysis is adjusted. This is mainly due to its proximity to Wen 102

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Dan Tang, the leading formula of the Phlegm-Heat pattern. These two formulas not only share ingredients such as chenpi, banxia and fuling but also have many SSs in common and share pathological pathways (excessive diet and spleen deficiency). According to our study, PhlegmHeat can actually be considered as a consequence of Food Stagnation.

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Chapter 7

Atypical Patterns of Insomnia Besides the seven patterns described in Chapter 6, we identified four ‘atypical’ patterns through thematic analysis (analysis of words instead of formula composition). These atypical patterns cannot be identified with the ingredients of the formula as they do not represent one single direction but rather a higher conceptual level. Therefore, the formulas of one atypical pattern can cover the range of several ‘typical’ patterns (see Table 7.1). The five atypical patterns are ‘Non-Interaction between Heart and Kidney (Non-Int H-K)’, ‘Qi and Yang Deficiency (Qi/Yang Def)’, ‘Stomach Disharmony (Sto Dis)’, ‘Disharmony between Nutritive and Protective (N-P Dis)’, and ‘Heart and Gallbladder Deficiency (H-G Def)’ (Table 7.1). Table 7.1. Main characteristics of atypical patterns Atypical pattern

Main formulas

Typical pattern classification

Formulas number

Non-Int H-K

Huang Lian E Jiao Tang, Jiao Tai Wan, modifications of Liu Wei Di Huang Wan

Yin Deficiency and Fire, Phlegm-Heat

75

Qi/Yang Def

Shen Qi Wan, Gui Zhi Gan Cao Long Gu Mu Li Tang, Bu Zhong Yi Qi Tang and Qian Yang Dan

Yin Deficiency and Fire, Classical Formulas

67

Sto Dis

Bao He Wan, Wen Dan Tang, Ban Xia Shu Mi Tang

Phlegm-Heat, Classical Formulas, Liver Stagnation

47

N-P Dis

Gui Zhi Tang, Gui Zhi Jia Long Gu Mu Li Tang

Classical Formulas

18

H-G Def

An Shen Ding Zhi Wan, combination of Suan Zao Ren Tang and An Shen Ding Zhi Wan

No equivalence

39

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1. Non-Interaction between Heart and Kidney When people are going to sleep the yangqi of the upper jiao descends and is hidden, it meets with the yinqi of the lower jiao, therefore the yin and yang can support each other, the heart and kidney communicate naturally… This is how we know that sleep is due to the yangqi hiding and insomnia is caused by the yangqi floating. Yixue Zhongzhong Canxi Lu

Chinese medicine focuses on the balance of different energies in the body. The heart is located in the upper burner, at the top of the body, and is associated with the element (or movement) fire. The kidney is located in the lower burner, at the bottom of the body, and is associated with the element (or movement) water. In order to keep a balance within the body, the water of the kidney has to go up and connect with the heart, keeping its fire controlled; the fire of the heart has to go down and connect with the kidney, keeping it warm. The absence of interaction between heart and kidney causes an imbalance in the body and can provoke medical conditions such as insomnia. Four different types of situations (or patterns) of Non-Interaction between Heart and Kidney have been found (Table 7.2). Kidney Yin Deficiency and Heart Fire Excess are relative to each other and appear most of the time simultaneously; therefore, treatment should combine both aspects by using a combination of Huang Lian E Jiao Tang and Jiao Tai Wan, for example. Table 7.2. Non-Interaction between Heart and Kidney patterns, pathological mechanisms and related formulas Pattern

Mechanism

Formulas

Kidney Yin Deficiency

The yin-essence of the kidney is exhausted because of aging, chronic illnesses, etc., and cannot interact with the heart

Huang Lian E Jiao Tang, Tian Wang Bu Xin Dan, Liu Wei Di Huang Wan, Zuo Gui Wan

Heart Fire Excess

Excessive emotions create fire in the heart, preventing its yang from connecting with the kidney

Jiao Tai Wan

Kidney Yang Deficiency

Kidney yang is too weak to steam the kidney yin upward to the heart

Qian Yang Dan, Er Xian Tang, Shen Qi Wan

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Mechanism

Formulas

Pathogen in the Middle Burner

The interaction between heart and kidney is blocked by an excess pathogen in the middle burner such as dampness, phlegm and food, in relation to spleen deficiency

Ban Xia Xie Xin Tang, Er Chen Tang, Wen Dan Tang

2. Qi and Yang Deficiency 2.1. Description of Qi/Yang Def Generally, warm-tonifying herbs are not recommended for insomnia (see Chapter 16). However, they can be used in cases of qi or yang deficiency. There are two different situations. In the first situation, warm-tonifying herbs are added to another formula, such as adding renshen in the case of deficiency pattern (1), using 3–6g (up to 9g maximum) of fuzi in the case of kidney yang deficiency, or adding 30g of zhi huangqi in the case of persistent insomnia or insomnia in older adults. In the second situation, a pattern of qi or yang deficiency is diagnosed and a warming treatment given accordingly. The pattern can be diagnosed based on the SSs or on the absence of response to the treatment (3).

2.2. Diagnostic characteristics of Qi/Yang Def Qi and yang deficiency is associated with older adults (12), persistent insomnia (5) and treatment-resistant insomnia (3). According to the clinicians, the main causes of qi and yang deficiency are: 1. exhaustion (from study, work, etc.) (12) 2. catching cold (10), usually because of living and working in an environment with air-conditioning or because not wearing enough clothes 3. aging (9) 4. deficient constitution (9) 5. cold drinks and food (9) such as cold beer, cold soft drinks, ice cream, raw food and fruits 6. excessive diet (eating too much fat and sugar, irregular meals) harming the spleen (9) 7. use of medication of a cold nature (6) such as heat-clearing herbs, antibiotics and steroids

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8. stress and emotions (6) 9. staying up late at night (6) 10. consumption from chronic illnesses (5) 11. therapeutic mistakes (2) such as excessive sweating 12. excessive sexual life (2) 13. surgeries and chemotherapy (1) 14. lack of physical activity (1) 15. abundant sweating (1).

2.3. The pathological mechanism of Qi/Yang Def Qi or yang deficiency as a cause of insomnia is somehow counterintuitive. The mechanisms by which qi or yang deficiency can provoke insomnia can be divided into two groups, spleen deficiency and yang deficiency. When the transportation and transformation function of the spleen is impaired, phlegm, dampness, food and fire stagnate; they can disturb the heart-shen or prevent interaction between heart and kidney. The spleen, impaired, cannot create qi and blood, which impacts the nutrition of heart-shen. Spleen deficiency can also provoke yin fire or an inability of the earth to hide the fire, both disturbing the heart-shen. Finally, as the spleen controls thinking, spleen deficiency can provoke overthinking and cognitive distortions which are intertwined with depression and anxiety, provoking insomnia. When insomnia…is developed internally, there are some cases of yang deficiency constitution. Because the kidney yang is deficient it cannot stimulate the Genuine Water to ascend and communicate with the heart, the heart qi cannot descend which causes insomnia. Yifa Yuantong

As for yang deficiency, the yang may be unable to nurture the heart-shen, partly because the heart yang cannot push the blood to nurture the brain or heart-shen. When kidney yang is deficient, it cannot steam the kidney yin to the heart, which becomes excessive and disturbs the heart-shen. The deficient yang may also be unable to self-contain, may float on the top and exterior and be unable to go back to the yin. Yang deficiency can create excessive yin which pushes the deficient yang upward and outward or prevents the yang from returning to the yin.

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2.4. Prescriptions for Qi/Yang Def After purge and sweating methods, the patient is agitated and cannot sleep during the day and becomes calm at night, there is no vomiting, no thirst, no external pattern, the pulse is deep and faint, there is no significant fever, Gan Jiang Fu Zi Tang is indicated. Shanghan Lun article 61

In total, qi and yang deficiency patterns were reported in 55 CERs, including 67 different patterns and associated formulas. The patterns reported were clustered into six different categories: Heart Yang Deficiency (6), Spleen Yang (or Qi) Deficiency (15), Kidney Yang Deficiency (including ‘Heart and Kidney Yang Deficiency’ and ‘Spleen and Kidney Yang Deficiency’) (39), Liver Coldness or Liver Qi Deficiency (3), Lung Qi Deficiency (1) and Cold-Dampness (1). The formulas associated with these patterns are shown in Figure 7.1. The characteristics of yang deficiency in general and of the main pattern categories are shown in Table 7.3. Shen Ling Bai Zhu San Wu Ling San

Gui Pi Tang

Qian Yang Dan

Gui Zhi Gan Cao Long Gu Mu Li Tang

Si Jun Zi Tang

Wu Zhu Yu Tang Wen Shen Yang Gan Fang

Shen Qi Wan Li Zhong Wan

Er Xian Tang Yi Shen Zhuang Yang Tang Yang Xin Tang Gui Zhi Gan Cao Tang Jiao Tai Wan Xiang Sha Liu Jun Zi Tang Huang Tu Tang Kong Sheng Zhen Zhong Dan Cu Pi Zhi Shen Tang Wu Zhu Yu Tang Si Ni San Li Zhong Wan

Bu Zhong Yi Qi Tang

Gui Zhi Gan Cao Tang Fu Ling Si Ni Tang You Gui Wan Ding Kou Li Zhong Wan Si Ni Tang Fu Zi Tang Xiang Sha An Shen Wan

Er Chen Tang

Gui Zhi Tang You Gui Yin An Shen Ding Zhi Wan

Feng Sui Dan

Gui Zhi Gan Cao Long Gu Mu Li Tang Tong Mai Si Ni Tang Nuan Gan Jian

Ma Huang Fu Zi Xi Xin Tang Ling Gui Zhu Gan Tang

Gan Jiang Fu Zi Tang

Fu Zi Li Zhong Tang Da Bu Gan Tang

Figure 7.1. Word cloud of the formulas used for Qi and Yang Deficiency patterns The size of the words is proportional to the number of citations.

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Table 7.3. Specificities, herb combinations and specific SSs of yang deficiency in general and different pattern categories Pattern

Characteristics

Herb combinations

Specific SSs

General Yang Deficiency

Lack of warmth and energy

1. Warm herbs (guizhi, ganjiang, fuzi) 2. Sweet herbs (dangshen, gancao) 3. Spirit-calming herbs (suanzaoren, yuanzhi)

Fatigue, aversion to cold, cold hands and feet, pale tongue with white coating and weak pulse

Heart Yang Deficiency

Heart yang floating on the exterior

1. Warm-tonifying (guizhi, gancao) 2. Collecting herbs (longgu, muli)

Palpitations, sweating and stuffy chest with light pain

Spleen Yang Deficiency

Stagnation of phlegm, liquid retention, water and dampness

1. Sweet-tonifying herbs (dangshen, baizhu, huangqi) 2. Dampnesstransforming herbs (chenpi, banxia, sharen) 3. Water-draining herbs (fuling, zexie)

Yellow complexion, lack of appetite, abdominal distension, nausea, loose stools and diarrhoea, large tongue with teeth marks and slimy fur

Kidney Yang Deficiency

Deficiency yang floating on the top

1. Warm-tonifying herbs (tusizi, yinyanghuo, bajitian, duzhong) 2. Rich-tonifying herbs (shudi, guijia, gouqizi, huangjing) 3. Pungent-hot herbs (fuzi, rougui, ganjiang) 4. Collecting herbs (longgu, muli, baishao, wuweizi)

1. Signs of fire on the top such as agitation, headaches, vertigo, tinnitus, red complexion, dry mouth and throat, mouth ulcers, sore throat, tooth ache and gum bleeding 2. Kidney deficiency signs such as dark complexion, coldness and pain in the lower back and knees, infertility, erectile disorder, irregular periods, frequent urination, oedema and diarrhoea

2.5. Clinical pearls for Qi/Yang Def The clinicians reported several recommendations when treating qi and yang deficiency patterns:

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1. One should be careful to not use excessively warm and dry herbs (1). 2. Heavy-sedative herbs (3), yin-nurturing herbs (1) and liver-calming herbs (1) should be combined with the warm and dry herbs to prevent them from being harmful. 3. Floating of deficient yang can easily be taken as hyperactive liver yang and treated inappropriately (1). 4. As spleen deficiency can create phlegm, the phlegm-heat pattern can resemble the spleen deficiency pattern, but it is inappropriate to use tonifying herbs in that case (1). 5. Warm-tonifying herbs should not be used if the meridians are blocked (1), in the case of excessive or deficient heat (1) or in the case of hypertension (1). 6. Qi and yang deficiency can be intertwined with excess patterns, either because it was caused by liver stagnation and blood stasis (1) or because it can create phlegm-fire (1). In this case, the treatment should take account of both deficient and excessive aspects (1). Case #1. A 29-year-old female consulted for difficulty falling asleep and frequent dreams for three months. She had had a weak constitution since childhood and had frequent colds. She had work stress and had been working late at night for three months and started to experience difficulty falling asleep, frequent dreams, light sleep and difficulty getting back to sleep after waking up. She slept approximately three hours per night, had dizziness, fatigue, agitation, irritability, abundant sweating on the head, lower back weakness, aversion to cold, cold limbs (especially the lower limbs), abdominal pain before menstruation, and menstrual bleeding was of a small amount and dark. Her appetite and urine were normal, and stools were soft. Her tongue was pale and large with teeth marks, the coating was thin and yellow; her pulse was deep and weak. She was diagnosed with kidney yang deficiency and ascension of deficient yang and was prescribed the following herbs: shudihuang 20g, shanyao 10g, shanzhuyu 15g, fuling 12g, zexie 10g, wuweizi 12g, zhi fuzi 12g, rougui 3g (powder to swallow directly), guijia 12g, paojiang 10g, yejiaoteng 18g and dengxincao 15g. After 21 bags, the insomnia was cured. Case #2. A 43-year-old female consulted for bad sleep quality for one week. She had trouble falling asleep and was waking up frequently,

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was significantly tired in the morning, felt her face was very dry, was agitated and had a dry mouth with a preference for cold drinks; she did not have palpitations, and there was no chest tightness or abdominal pain. She usually had cold hands and feet, sweated easily from the palms and had a history of PCOS. Her stools were loose and she had frequent urination. The diagnosis was heart and kidney yang deficiency with non-interaction between heart and kidney. She was prescribed a granule formula of pao fuzi 3g (cooked longer), huangbai 10g, zhimu 10g, sharen 6g (added at the end), cu guijia 10g, guizhi 10g, zhi gancao 10g, sheng longgu 20g (cooked longer), sheng muli 20g (cooked longer) and fushen 30g. After five bags, sleep was significantly improved and her symptoms were reduced.

3. Stomach Disharmony 3.1. Definition The yangming is the stomach channel. The stomach is the sea of the six fu organs, its qi is also moving downward. In the case of inversion of the yangming, [the qi] does not follow its pathway, therefore there is insomnia. This is what the Inferior Classic means when it states ‘the sleep is disturbed in case of stomach disharmony’. Suwen chapter 34

The meaning of Stomach Disharmony is vague, as it can refer either to a symptom of stomach discomfort or a pathological mechanism. It can also refer to an acute or a chronic condition. In the case of referring to a symptom, a ‘stomach distention and pressure with pain…is accompanied by insomnia, principally a difficulty to fall asleep’. However, Stomach Disharmony can also refer to a pathological mechanism only, as stomach bloating or pain is absent from certain patterns of Stomach Disharmony such as the Wen Dan Tang pattern or Gui Pi Tang pattern. In most cases, it is impossible to differentiate the two as stomach discomfort is present as part of the SSs related to the pathological mechanism of Stomach Disharmony. Stomach Disharmony is sometimes associated with an acute condition of ‘Food Damage’, a concept similar to indigestion in which excessive food intake or food intake just before bedtime leads to stomach bloating, nausea, acid reflux and eructation. It can also be

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associated with chronic digestive conditions such as ‘chronic gastritis, gastric ulcer, duodenitis or gastroptosis’. Finally, Stomach Disharmony is associated with children (3) and older adults (2), who have a weaker digestive system.

3.2. Pathological mechanisms Stomach Disharmony as a pattern is complex and multifaceted. The core of the pattern is either food stagnation or phlegm(-heat), the former leading to the latter. The difference between food stagnation and phlegm is often unclear and the treatment sometimes similar. Additional mechanisms such as spleen-stomach qi stagnation, spleen (yang) qi deficiency, liver qi stagnation and stomach yin deficiency are enmeshed with the core mechanisms, and therefore the treatment is never focused on one specific mechanism. There are several explanations for how Stomach Disharmony can provoke insomnia. First, the sensation of stomach discomfort is an ‘impulse sent by the digestive tube that excites the reticular system in the brain stem, which in turn excites the cerebral cortex’. A more common explanation for chronic conditions is that the excessive pathogen (e.g. food stagnation, phlegm-heat) disturbs the spirit. The stagnation of an excessive pathogen in the middle burner can also block the interaction between heart and kidney; the heart fire is excessive in the upper burner and disturbs the spirit. In this case, one clinician recommended first treating the spleen and stomach and then improving the interaction between the heart and the kidney. Finally, when the spleen is deficient, its function of producing qi and blood is impaired and the spirit cannot be nurtured, which can also lead to insomnia. 3.3. Categories of formula As the mechanism of Stomach Discomfort is complex and all its different components intertwined, it was impossible to categorize the formulas of Stomach Discomfort. These formulas are shown in Figure 7.2. The two major formulas are Bao He Wan and Wen Dan Tang. Case #1. A female patient was treated for insomnia for two years. The patient has trouble falling asleep, frequent dreams and light sleep. She needed a half pill of estazolam to fall asleep. The patient is worried easily, agitated, irritable, has a stomach sensitive to cold, lack of appetite, gastric bloating after eating, eructations, no acid reflux, cold legs and

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sometimes dry stools. The tongue is red, the coating white and slightly greasy with some teeth marks; the pulse is deep and slightly wiry. She was prescribed a decoction with fuling 20g, shanyao 20g, yiyiren 20g, oujie 20g, chao maiya 20g, jiao guya 20g, tianhuafen 20g, shenqu 10g, suanzaoren 15g, hehuanpi 15g, shouwuteng 15g, baiziren 15g to take two times a day and a granule formula with dangshen 10g, zhiqiao 10g, duhuo 10g to take in the morning only. After two months of treatment, sleep was improved and the symptoms were removed. Chai Hu Shu Gan San Ma Zi Ren Wan Yue Ju Bao He Wan Zhi Zhu Wan Ban Xia Xie Xin Tang

Huang Gui Lian Wen Dan Tang Si Mo Yin Zhi Tang He Wei An Shen Tang

Shu Gan He Wei Wan

Wei Ling Tang Xiao Xian Xiong Tang Wu Zhu Yu Tang

BaoXiang HeShaWan Liu Jun Zi Tang

Dao Tan Tang Bu Zhong Yi Qi Tang Zhi Shi Dao Zhi Wan

Yi Wei Tang Gui Pi Tang

Yi Gong San

Ban Xia Hou Po Tang

Xiao Yao San

Ping Wei San Tiao He Cheng Qi Tang Si Jun Zi Tang Zhu Ye Shi Gao Tang Mai Men Dong Tang Qing Wei San

Tiao Zhong Hua Tan An Shen Tang

Wen Dan Tang Chai Ping Jian

Nuan Gan Jian Hua Gan Jian Yue Ju Wan

Si Qi Tang

Hao Qing Qing Dan Tang Zao Ban Tang Zuo Jin Wan Qing Huo Di Tan Tang

Ban Xia Shu Mi Tang Liu Jun Zi Tang

Jiao San Xian

Suan Zao Ren Tang Shi Wei Wen Dan Tang

Figure 7.2. Formulas used for Stomach Disharmony The size of the words is proportional to the number of citations.

Case #2. A 35-year-old female consulted for insomnia and gastric distension for two weeks. She presented with insomnia, could sleep only 2–3 hours per night, had dizziness, agitation, lack of appetite, nausea after eating, eructations, acid reflux, bad breath; stools were sticky and smelly and passed 2–3 times per day. Her tongue was red, and the coating was yellow, thick and greasy; the pulse was wiry, slippery and rapid. This is a pattern of food stagnation creating heat and causing stomach disharmony. She was prescribed jiao shenqu 40g, jiao maiya 40g, jiao shanzha 40g, jiao binglang 40g, chao laifuzi 30g, zhishi 10g, huangqin 10g, lianqiao 10g, jineijin 10g, houpo 10g, huoxiang 10g, peilan 10g, banxia 12g, fuling 12g, chenpi 12g. After five bags, sleep had improved and the symptoms disappeared.

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4. Disharmony between Nutritive and Protective 4.1. Definition of N-P Dis The theoretical background behind Disharmony between Nutritive and Protective as a pattern of insomnia is the idea that the sleep–wake cycle is related to the movements of the protective qi, which circulates in the yang when we are awake and in the yin when we are asleep. Another theory is that, according to the classic Huangdi Neijing, ‘the nutritive and protective have to be regulated when the heart is damaged’. According to the clinicians, there are three different aspects of Disharmony between Nutritive and Protective – namely, nutritive and protective qi deficiency, a stagnation of the nutritive and protective qi, and an imbalance between nutritive qi and protective qi. The first and second aspects are linked as the nutritive and protective have to be both sufficient and moving to be effective. In the third aspect, the protective is excessively strong and cannot penetrate the nutritive-yin.

4.2. Prescription for N-P Dis This separation does not matter in terms of treatment as Gui Zhi Tang and its modified forms can be used to address these three aspects – it can tonify and move the nutritive and protective, and also bring the protective back to the nutritive-yin. However, the primary cause of the disharmony has to be addressed. For example, if the deficiency of the nutritive and protective is due to spleen deficiency, it has to be treated with Si Jun Zi Tang. If the lack of movement of the nutritive and the protective is due to a global stagnation in the three burners, it has to be treated with Xiao Chai Hu Tang. The formulas used for this pattern are shown in Figure 7.3. Er Chen Tang

Si Jun Zi Tang

Gui Zhi Tang Ban Xia Xie Xin Tang

Gui Zhi Jia Long Gu Mu Li Tang Xiao Chai Hu Tang Sheng Yang Yi Wei Tang Dang Gui Bu Xue Tang

Figure 7.3. Formulas used for Disharmony between Nutritive and Protective The size of the words is proportional to the number of citations.

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4.3. Diagnostic features of N-P Dis The indications for Disharmony between Nutritive and Protective can be different depending on the definition of this pattern. For example, the indication for Ban Xia Xie Xin Tang is ‘low mood, sadness, difficulty falling asleep, frequent sighing, fatigue, lack of appetite, deep and wiry pulse’; the indication for Gui Zhi Jia Long Gu Mu Li Tang is ‘vertigo, hair loss, abdominal pain, sperm emission, light tongue, thin white coating, deficient or slow pulse’; and the indication for Gui Zhi Tang is ‘difficulty falling asleep, bad sleep quality, frequent dreams, frequent awakenings, vulnerability to catching cold, palpitations, breathlessness and sweating after effort, vertigo’. According to the clinicians, Disharmony between Nutritive and Protective can be diagnosed when there is no significant imbalance between yin and yang (1) or no significant deficiency (1), and especially in the case of external affliction (1).

5. Heart and Gallbladder Deficiency 5.1. Definition of H-G Def The Heart and Gallbladder Deficiency pattern is also called Heart Deficiency and Timidity pattern. This pattern is not typical as it represents a psychological characteristic – literally a small-gallbladder (danxiao 胆 小) – which can be translated as timidity, cowardice or lack of courage. It is also associated with an inability to make decisions (jueduan 决断), which is the function of the gallbladder. This pattern is associated with psychological disorders such as depression or neuroticism (1).

5.2. The pathological mechanism of H-G Def Heart and Gallbladder Deficiency is mainly caused by: 1. constitutional weakness (15) manifested by a tendency to be easily frightened (6), introversion (1) and a sensitive personality (1) 2. sudden panic (14) related to a trauma 3. excessive emotions (1) 4. severe or long-term diseases (1). The mechanism of this pattern is more vague, as the direction of the pattern in terms of deficiency/excess and heat/cold is not as clear as in other patterns. The ‘deficiency’ in the name of the pattern shows a

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tendency toward a deficiency pattern; however, both tonifying herbs and eliminating herbs are used for this pattern. Heart and Gallbladder Deficiency is associated with: 1. 2. 3. 4. 5. 6.

qi and blood deficiency (2) liver stagnation (2) phlegm (2) liver blood deficiency (1) yang deficiency (1) spleen deficiency (1).

5.3. Diagnostic features of H-G Def The SSs associated with Heart and Gallbladder Deficiency are shown in Figure 7.4. These are mainly psychological symptoms and physical symptoms related to anxiety such as breathlessness, palpitations, sweating and fatigue. excessive preoccupation

spontaneous sweating large tongue aversion to noise

agitation

sadness

dark complexion

breathlessness

lack of appetite

fatigue

vertigo

frequent awakenings

pale tongue aggravation aer panic

wirylight and thready pulse and abundant urine

tendency to panic

wiry pulse pale red tongue

panic awakenings anxiety

thready pulse

wiry, thready and weak pulse

palpitations wiry, thready and relaxed pulse

light sleep difficulty falling asleep

red tongue

all-night insomnia tight pulse

frequent dreams thin white coating thready and rapid pulse

timidity/cowardice

thready and weak pulse

nightmares

thready and relaxed pulse

Figure 7.4. Signs and symptoms associated with Heart and Gallbladder Deficiency The size of the words is proportional to the number of citations.

5.4. Prescriptions for H-G Def The formulas used to treat Heart and Gallbladder Deficiency are: 1. An Shen Ding Zhi Wan (20) 2. the combination of An Shen Ding Zhi Wan with Suan Zao Ren Tang (9)

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3. Chai Gui Wen Dan Ding Zhi Tang (1) 4. the combination of Sheng Mai San and Suan Zao Ren (1) 5. Xiao Chai Hu Tang (1) 6. Bu Xin Zhuang Dan An Shen Tang (1) 7. Gan Dan Liang Yi Tang (1) 8. Wu You Tang (1) 9. Hu Zhu San (1) 10. Wen Dan Tang (1) 11. several self-designed formulas. When there is agitation caused by wind-cold with heat transmitted to the heart or summer-heat attacking the heart, the spirit can be calmed by the clearing method. When there is agitation caused by internal coldness, the spirit can be hidden by the warming method. When there is insomnia caused by panic, the patient experiences panic and palpitations in his/her dreams, An Shen Ding Zhi Wan is indicated. Yixue Xinwu

The composition of the formulas of this pattern is mainly a mix of ­spirit-calming herbs (including both heart-nurturing and heavy-­sedative herbs) and qi-tonifying herbs such as renshen, dangshen and gancao. Sometimes, phlegm-transforming, blood-nurturing, heat-clearing and liver-draining herbs are added to the formula.

6. Interpretation and discussion The five atypical patterns identified in this chapter represent five important concepts in the pathology of insomnia. As the conceptual architecture of these concepts is different from the mainstream organ diagnosis system (e.g. liver fire, kidney deficiency), they are not represented by a core group of herbs and therefore not detected by the cluster analysis. That being said, their relationships with the typical pattern system vary widely. Non-Int H-K is very similar to the typical pattern Yin-­ Def-Fire as it is built on the same main pathological mechanisms – that is, kidney deficiency and heart fire. The only difference is that Non-Int H-K integrates middle jiao issues, which block the communication between heart and kidney. H-G Def has no direct relationship with any typical pattern as its main formulas, An Shen Ding Zhi Wan and

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Suan Zao Ren Tang, tend to jump from one typical pattern to another depending on the parameters of the cluster analysis. The clarity of the definition of these atypical patterns varies greatly. Qi/Yang Def has very strict categories with clear explanations regarding the pathological mechanism. This is not the case for N-P Dis, for which there is no clear consensus on what it is, why it causes insomnia and how to manage this pattern. The term ‘stomach disharmony’ can refer to various situations (indigestion or chronic digestive condition) and different conceptual levels (symptom or mechanism). Despite being composed of 67 formulas, which makes it larger than most typical patterns, Qi/Yang Def is completely absent from current textbooks and guidelines. This may be because it challenges the idea that insomnia is a condition in which ‘the [excessive] yang cannot penetrate the [deficient] yin’. According to mainstream views, using tonic herbs for insomnia is somehow taboo. This study shows that this is not completely true, and that tonic and warm herbs should be used when appropriate. These herbs have yet to be used carefully and to be combined with heavy-sedative herbs or rich-tonifying herbs. The Sto Dis pattern spreads across various typical patterns such as Liver Stag, L-S Def, Phlegm-Heat and H-S Def. This shows that although there is no typical pattern of insomnia focused on the spleen-stomach, regulating the spleen and stomach is a background strategy that has to be considered for various patterns (see also Chapter 16).

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Classical Formulas In the original analysis, classical formulas such as Xiao Chai Hu Tang and Gui Zhi Tang were combined in the same cluster. Although these formulas share common ingredients such as shengjiang, dazao and gancao, the direction of their effect is, arguably, quite different. Moreover, there were significant differences in the way the classical formulas were presented compared with other formulas. For example, dosage is often presented in multiples of 3 (e.g. 9g, 12g) and six channel diagnosis is more common. There is significantly less consensus for the patterns associated with these formulas than for other formulas. For the above reasons, we decided to separate the cluster ‘classical formulas’ from the rest of the typical patterns and present each formula individually. Suan Zao Ren Tang was initially in the ‘Yin Deficiency with Fire’ pattern, yet this was not always the case in the different tests we ran before deciding on the final analysis. Suan Zao Ren Tang was also significantly different from other formulas in the ‘Yin Deficiency with Fire’ pattern in terms of pattern name, associated signs and symptoms, etc. Therefore, we decided to include it in the Classical Formulas rather than the ‘Yin Deficiency with Fire’ pattern.

1. Suan Zao Ren Tang (32) 1.1. Original indication Chronic exhaustion with empty agitation and inability to sleep, Suan Zao Ren Tang is indicated. Jin Gui Yao Lue chapter 6

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1.2. Associated patterns In the CERs, Suan Zao Ren Tang (SZRT) was proposed 15 times individually and 17 times combined with at least one other formula. The formulas combined with SZRT include An Shen Ding Zhi Wan (3), Xiao Yao San (2), Huang Lian E Jiao Tang (2), Chai Hu Shu Gan San, Chai Hu Jia Long Gu Mu Li Tang, Yue Ju Wan, Shu Gan Yin, Long Dan Xie Gan Tang, Sheng Mai San, Gan Mai Da Zao Tang, Gui Zhi Qu Shao Yao Jia Shu Qi Mu Li Long Gu Jiu Ni Tang, Gui Pi Tang, Gan Cao Mai Dong Zao Ren Tang, Cu Mian Fang, Wen Dan Tang, Dang Gui Liu Huang Tang, Tian Wang Bu Xin Dan. The following content applies only to SZRT used individually. SZRT was associated with ‘liver blood deficiency and empty heat’ (3), ‘liver blood deficiency’ (3), ‘blood deficiency’ (1), ‘heart and gallbladder qi deficiency’ (1) and ‘liver qi stagnation and blood deficiency’ (1) patterns. 1.3. Cause Excessive emotions (2), sudden fright (1), aging (1), excessive preoccupation (1), loss of blood (1), exhaustion (1) causing a deficiency of yin and blood and empty heat. This pattern can also be developed from kidney yin deficiency (1). The insomnia is caused both by lack of blood to nurture the heart-spirit and heat perturbing the heart-spirit. 1.4. Signs and symptoms The most common signs and symptoms of the SZRT pattern are palpitations (8), agitation (7), dizziness and vertigo (7), fatigue (5), dry mouth and throat (4), dull complexion (2) and loss of memory (2). The types of insomnia are mainly frequent dreams (4), difficulty falling asleep (2) and awakenings in panic (2). The tongue can be pale (3), light red (1) or red (5) with a yellow coating (2), white coating (1) or lack of coating (1). The pulse can be wiry and thin (5), thin and rapid (2), wiry, thin and rapid (3) or thin and weak (1). 1.5. Ingredients The ingredients (with average dose, minimum dose and maximum dose) are: 1. suanzaoren, stir-fried (7), 27.0g (15–90g) 2. fuling, 15.5g (9–20g) 3. zhimu, 12.7g (9–20g)

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4. chuanxiong, 10.4g (3–20g) 5. gancao, 7.0g (3–15g).

1.6. Analysis Suanzaoren, the sovereign of the formula, is sour, sweet and neutral. Due to its sour taste, it can collect the yang and return it to the yin section. Due to its sweet nature, it can nurture yin and blood. Suanzaoren can also calm the shen. Fuling and zhimu are the ministers. The main action of fuling is to calm the shen, although some clinicians mentioned that it is also used to strengthen the spleen (2) and transform phlegm (2). Zhimu, which is sweet and cold, nurtures yin and clears heat. The combination of suanzaoren, fuling and zhimu can calm the shen and reduce agitation. Chuanxiong can soothe the liver. The combination of chuanxiong (pungent) and suanzaoren (sour) is ideal to regulate the liver. Gancao is used mainly to regulate the ingredients of the formula. One clinician mentioned that the combination of gancao and fuling can regulate the stomach. Another explanation of SZRT is based on the Huangdi Neijing, which states that ‘the liver suffers from tension; when there is tension use sweet taste to relax it’ and ‘the liver desires dispersion, when impaired use pungent taste to disperse it; pungent taste is used to tonify it and sour taste is used to drain it’ (Suwen chapter 22). In this context, SZRT is used to regulate the liver, with the pungent taste of chuanxiong used to tonify the liver, the sour taste of suanzaoren used to drain the liver and the sweet taste of gancao used to relax the liver. 1.7. Modifications In the case of heart and spleen deficiency, add dangshen and baizhu; in the case of yin deficiency and fire add maidong, nvzhenzi and hanliancao; in the case of stomach disharmony, use shenqu, shanzha and laifuzi; in the case of liver fire, add longdancao, huangqin and zhizi; in the case of phlegm, add chenpi, banxia and yuanzhi. 1.8. Clinical tips 1. ‘Zhi Zi Chi Tang and Suan Zao Ren Tang can be both used to treat empty agitation with insomnia. However, “vexation in the heart” is present only in Zhi Zi Chi Tang syndrome.’ 2. ‘When using this formula [Suan Zao Ren Tang]…the time of administration is 1h before dinner and 2h before bedtime.’

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3. Use high doses of suanzaoren (6), up to 180g (1). 4. Suanzaoren is not appropriate when the coating is greasy (1). 5. Use suanzaoren stir-fried for liver blood deficiency and raw for liver heat (1). 6. In the case of severe insomnia or all-night insomnia, use fushen instead of fuling or add gansong to fuling (1). 7. As the liver is a hard organ, it relies on yin-blood for nutrition. Don’t use too much of chuanxiong to prevent it from aggravating the dryness and heat (1).

1.9. Relevant citations If the deficiency of essence and blood is combined with accumulation of phlegm and qi manifested with palpitations and agitation at night, the Suan Zao Ren Tang from Secret Formulas [ingredients: suanzaoren, yuanzhi, huangqi, lianzirou, renshen, danggui, fuling, fushen, chenpi, zhigancao] is indicated. Jingyue Quanshu chapter 18

When there is no evil, insomnia is necessarily caused by a lack of nutritive and blood. The nutritive governs the blood, when blood is deficient it cannot nurture the heart, when the heart is deficient the shen cannot stay in its home. Jingyue Quanshu chapter 18

1.10. Clinical cases Case #1. A 74-year-old male consulted for insomnia for 20 years, aggravated for 30 years. Twenty years ago, the patient was excessively preoccupied after the loss of his son and started to be unable to sleep every night. He had been taking a sedative ever since. Thirty days previously, he started to be unable to sleep without any obvious reason and diazepam was ineffective. The clinical manifestations include agitation, insomnia, dizziness and palpitations. His tongue was light red and the pulse wiry and thin. The pattern was heart blood deficiency with shen not being nurtured. The patient was prescribed Suan Zao Ren Tang: suanzaoren 30g, zhimu 9g, chuanxiong 9g, fuling 15g, gancao 6g,

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danshen 12g and baiziren 9g. The patient’s sleep started to improve the day after the first treatment. He took in total 16 bags and efficacy was stable at a six-month follow-up. Case #2. A 62-year-old female consulted for insomnia for more than ten years. Ten years ago, the patient had mental stress due to a diagnosis of diabetes and started to have difficulty falling asleep and early-morning awakenings. The situation progressively deteriorated, and she was taking eszopiclone regularly. Sometimes she needed to take three tablets of eszopiclone to sleep 3–4 hours. Clinical manifestations include difficulty falling asleep, difficulty going back to sleep after awakening, sleeping only 1–2 hours per night, irritability due to the insomnia. She was suffering severely and was almost suicidal. There was profuse sweating, palpitations, breathlessness, dry eyes, dry mouth and a bitter taste in mouth, dry nose, headaches aggravated in wet weather (she takes analgesics frequently), oedema in the legs during the afternoon but not in the morning. The tongue is dark with lack of coating, and the pulse is deep and thin. She had a left lung resection 2 years ago, cervical spondylosis for 20 years, a low left ventricular function and a ST-T segment change. The pattern diagnosis was deficiency of yin and blood. She was prescribed Suan Zao Ren Tang modified: chao suanzaoren 120g, zhimu 45g, chuanxiong 15g, duan longgu 60g, quanxie 6g. The patient was asked to take the treatment after dinner and before bedtime. After seven bags the sleep had improved by 70%: she fell asleep more quickly and slept for five hours; her mood improved and she was full of hope for the future.

2. Xiao Chai Hu Tang (11) 2.1. Original indication On the fifth and sixth days of the cold damage, there is wind attack manifesting with alternating chills and fever, fullness in the chest and sides, mutism and no desire for food and beverages, agitation and frequent vomiting. There can be agitation in the chest and no vomiting, or [thoracic] fullness, or abdominal pain, or distension and hardness in the hypochondrium, or palpitations, or dysuria, or absence of thirst and light fever, or thirst. Xiao Chai Hu Tang is indicated. Shanghan Lun article 96

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2.2. Associated patterns The patterns associated with Xiao Chai Hu Tang (XCHT) include liver qi stagnation (2), blocked pivot (1), intense ministerial fire of shaoyang (1), shaoyang stagnation with gallbladder fire rising (1), liver fire perturbing the heart (1) and liver-stomach disharmony (1). It is worth noting that XCHT is often used on a disease-diagnosis basis. In this case, liver qi stagnation or blocked pivot are considered the core mechanism of insomnia itself. XCHT is commonly combined with Wen Dan Tang to treat shaoyang phlegm-heat. That combination is called Chai Qin Wen Dan Tang. 2.3. Cause The cause of the XCHT pattern is mainly excessive emotions (5) causing imbalance in qi movements. As the rising and descent of qi are impaired, it is difficult for the yang to return into the yin. One clinician explained that when the pivot is blocked, there is disharmony between interior and exterior in the shaoyang, disharmony between nutritive and protective in the taiyang, disharmony of the qi movements of the liver, gallbladder, spleen and stomach, and disharmony of the rising and descent of the kidney and heart (water and fire). 2.4. Signs and symptoms The signs and symptoms of XCHT include hypochondriac pain (4), eructations (4), chest tightness (3), gastric bloating (3), acid reflux (2), lack of appetite (2), bitter taste in the mouth (2), agitation (2), depressed mood (2) and abdominal distension (2). The tongue is red (1) with a slight yellow and greasy coating (1) and the pulse is wiry and strong (1) or wiry and thin (1). One clinician mentioned that the signs and symptoms of shaoyang disease are like the signs and symptoms of insomnia. 2.5. Ingredients Most clinicians proposed using the original formula. One clinician proposed adding xiangfu, chuanxiong, yujin, foshou, suanzaoren and yejiaoteng. Another proposed removing the tonic herbs renshen, dazao and gancao. Another removed shengjiang and dazao and added sheng longgu, sheng muli, xiakucao and baizhu. Another proposed replacing renshen with dangshen if the qi deficiency is not obvious or taizishen if the internal heat is strong. One clinician proposed using chaihu 25g, huangqin 10g, jiang banxia 10g, danshen 20g and zhi gancao 10g, while 124

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another one proposed using chaihu 10–15g (but 15–20g to unblock the three jiao), huangqin 10–15g and banxia up to 30g.

2.6. Analysis Chaihu is pungent, neutral, light and clear; it can soothe the liver and gallbladder and unblock the qi in the three jiao. Some clinicians cited the Shennong Bencao Jing stating that chaihu can ‘remove the knotted qi of the stomach’, improving sleep by harmonizing the stomach. Huangqin is bitter, cold, heavy and turbid; it can clear heat and drain fire. The combination of chaihu and huangqin can remove the stagnant qi from shaoyang. Banxia can harmonize the stomach and remove phlegm. Combined with chaihu, it can regulate the qi movements as ‘pungent taste opens and bitter taste descends’. Combined with huangqin, it can make yin and yang communicate. Several clinicians cited ancient and modern sources to show that banxia has shen-calming properties. Renshen, shengjiang, dazao and gancao can protect the spleen and stomach and regulate the nutritive and protective. 2.7. Clinical cases Case #1. A 53-year-old male employee consulted in July 1981 for insomnia for 23 years. He was diagnosed with schizophrenia in 1958. He had already recovered but still had insomnia. The insomnia was aggravated by emotional stimulation and the common cold, and sometimes he was unable to sleep for the whole night. He travelled everywhere for a cure but neither Chinese nor Western medicine could help him. The patient presented with dizziness, head pressure, tinnitus, blurred vision, red cheekbones, hot flushes, sometimes fever and chills, agitation, frequent vomiting, fullness in the chest and sides, and irritability. His appetite, stools and urine were normal. There was significant tenderness upon pressure on GB 22 and BL 15. The tongue was red with a thin coating and the pulse was wiry. This situation is caused by an abundance of ministerial fire of the liver and gallbladder. XCHT was used to harmonize the shaoyang and unblock the liver and gallbladder: chaihu 10g, huangqin 10g, chao dangshen 30g, fa banxia 10g, danpi 8g, wugong 6g, dazao 4 units, gancao 6g, shengjiang 2 slices. After two bags the sleep had improved, and all symptoms had disappeared after five bags.

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Case #2. A 58-year-old female consulted for difficulty falling asleep and night sweats for one year. When she woke up during the night, her clothes and bed sheets were soaked. This situation had worsened in the last six months. She tossed and turned before falling asleep and needed sedatives to fall asleep. She felt alternately hot and cold. Two to three hours after falling asleep, she woke up in panic. There was a feeling of oppression, palpitations, agitation, dry mouth and a bitter taste in mouth. Stools were normal. The tip of the tongue was red and there was a lack of coating. The pulse was wiry and thin. The Chinese medicine diagnosis was insomnia and the pattern was shaoyang ministerial fire rising and yin deficiency. The combination of XCHT and Bai He Di Huang Tang was used: chaihu 25g, huangqin 9g, qing banxia 9g, zhenzhumu 30g (cooked longer), fushen 12g, dangshen 9g, zhi gancao 9g, shengdihuang 15g, baihe 30g, shengjiang 5 slices, dazao 4 units. The traditional method of preparation is followed: the patient is asked to cook the herbs for 20 minutes, then remove the residue and cook again for 20 minutes. After 20 bags, the insomnia and night sweats were significantly improved, and she no longer needed sedatives to sleep. Case #3. A 46-year-old female consulted for insomnia for two years. Two years before, after a total hysterectomy for uterine fibroids, she started to develop agitation, irritability, insomnia and frequent dreams. She could only sleep 2–3 hours per night and sometimes not at all. She could sleep 3–4 hours using sedatives, but the problem returned after discontinuation. The insomnia worsened two weeks before due to excessive emotions. There was a hot feeling with no fever, sometimes a bitter taste in the mouth, lack of appetite, and gastric and abdominal bloating; stools were not evacuated easily, and urine was slightly dark. The side of the tongue was red, the coating yellow and greasy, and the pulse was wiry. This is a yinyang disharmony pattern. She was treated with chaihu 18g, huangqin 10g, dangshen 10g, banxia 30g, zhi gancao 10g, shengjiang 3 slices, dazao 4 units. The situation improved after seven bags and sleep returned to normal after ten more bags.

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3. Chai Hu Jia Long Gu Mu Li Tang (21) Original indication On the eighth and ninth days of the cold damage, the patient is purged, there is thoracic fullness, agitation and panic, dysuria, gibberish, the whole body is heavy with impossibility to change side, Chai Hu Jia Long Gu Mu Li Tang is indicated. Shanghan Lun article 107

3.1. Associated patterns Chai Hu Jia Long Gu Mu Li Tang, also called Chai Hu Long Mu Tang (CHLMT), is mainly associated with liver qi stagnation (8) producing fire (5) and phlegm (3), shaoyang pattern (2), blocked pivot (2) and gallbladder fire (2). Like XCHT (although less frequently), CHLMT can be used on a disease basis, as qi movement disharmony and blocked pivot can be considered as the core mechanisms of insomnia. CHLMT can be combined with Suan Zao Ren Tang (1), Huang Lian E Jiao Tang (1) and Tian Ma Gou Teng Yin (1). 3.2. Cause The main cause of CHLMT is excessive emotions (5) leading to liver qi stagnation (8), which in turn produces fire (6) and phlegm (2). One clinician pointed out that ‘emotions cause insomnia and insomnia cause emotions, leading to a vicious circle’. Alternative causes include external affection with transmission to shaoyang (1) and excessive use of herbs that block qi movements such as suanzaoren and zhenzhumu (1). One clinician pointed out that ‘unblocked pivot’ included shaoyang, but also shaoyin and the spleen and stomach. Another clinician cited the Huangdi Neijing, ‘the liver has the function of general’, to explain that the liver was not merely a ‘mental organ’ and CHLMT treats the impairment of liver functions such as ‘protecting the body from external pathogens, producing qi and blood, unblocking the qi movements of the organs, regulating the water pathway (triple burner), harmonizing nutritive and protective and promoting spleen and stomach movement and transformation’.

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3.3. Signs and symptoms One clinician pointed out that CHLMT included rich, varied and unstable signs and symptoms. The most common signs and symptoms of the CHLMT pattern are agitation (11), chest and side distension (10), anxiety (7), constipation (7), irritability (6), dizziness (5), bitter taste in the mouth (5), dry mouth (4), frequent sighing (4), dysuria (3), dark urine (3) and gibberish (3). The insomnia symptoms are mainly trouble falling asleep (6), frequent dreams (5), awakening in panic (3) and sleeptalking (2). The tongue is mainly red (9) with a yellow (6) or yellow and greasy (3) coating. The pulse is mainly wiry and rapid (5), wiry and slippery (3) or wiry and thin (2). The symptoms can also be aggravated by emotions (1) and the patient may not feel fatigue during the day despite having a bad sleep (1). 3.4. Ingredients The original ingredients of CHLMT are chaihu, huangqin, banxia, renshen, guizhi, fuling, dahuang, qiandan, shengjiang and dazao. In clinical cases, renshen was consistently replaced with dangshen or taizishen, and qiandan (lead), which is toxic, was consistently removed (or replaced with cishi). Dahuang, shengjiang and dazao were sometimes removed. Only one clinician mentioned that dahuang should be added later (as it is the case to increase the laxative effect). Sheng longgu (7) and sheng muli (5) were more commonly used than duan longgu (3) and duan muli (4). Fa banxia (4) was more commonly used than qing banxia (3) and jiang banxia (1). The average, minimum and maximum doses of the main ingredients are as follows: chaihu 15g (9–30g), huangqin 10g (6–15g), banxia 12g (6–30g), dangshen 15g (6–30g), longgu 24g (6–30g), muli 26g (6–50g), guizhi 10g (5–20g), fuling 11g (6–24g), dahuang 8g (3–12g). 3.5. Analysis The combination of chaihu and huangqin can harmonize the shaoyang and disperse the stagnant heat of the liver and gallbladder. Banxia is used to disperse and open stagnation, move down the inversion, and transform phlegm. Guizhi can unblock the yangqi and move down the inversion. Dahuang can help chaihu and huangqin to drain the internal heat. Fuling promotes urination and calms the spirit. Longgu and muli bring down liver yang and sedate.

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3.6. Modifications If liver fire is strong, bitter-cold herbs such as zhizi, longdancao and huang­lian can be used and the dose of dahuang can be increased to 10–15g. In the case of phlegm-heat, duan qingmengshi or zhuru can be added, or the formula can be combined with Wen Dan Tang. If the liver stagnation is severe, yujin or dandouchi can be added. 3.7. Clinical tips 1. You must use longgu, muli and cishi – none must be missing. 2. In this formula, use dahuang prepared (zhi 制) as it can drain the heat and tranquilize. If the patient can’t bear the purge, replace it by huanglian. 3. CHMLT is used to replace Dan Zhi Xiao Yao San when the liver fire is severe. 4. This pattern must not be treated with bitter-cold fire-draining formulas as they would congeal qi and blood and aggravate the fire. 5. During the treatment, the patient should avoid pungent and stimulating food and drink, quit smoking, limit alcohol consumption, regulate his/her emotions and have a regular schedule. 6. When the heat pathogen is severe use low doses of longgu and muli in order to avoid ‘keeping the robber when closing the door’. 7. This formula is appropriate for insomnia comorbid with anxiety, diabetes and Parkinson’s disease.

3.8. Relevant citation Liver-related insomnia is due to…the yang floating in the exterior, the hun does not enter the liver. Xuezheng Lun

3.9. Clinical cases Case #1. A 32-year-old male consulted for neurosis for more than ten years. He tried all kinds of sedative drugs without results. The patient had trouble falling asleep, frequent emission during his dreams, dizziness, tinnitus, chest tightness, palpitations and dark urine. His tongue

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was red with a thin yellow coating and the pulse was wiry and rapid. He was prescribed chaihu 18g, huangqin 12g, fa banxia 18g, dangshen 18g, duan longgu 30g, duan muli 48g, fuling 24g, dahuang 12g, guizhi 12g, shengjiang 6 slices and dazao 10 units. He was asked to grind the herbs and boil 27g of powder per day. After one course he could sleep six hours and the emission had stopped. The results were stabilized with a second course of treatment. Case #2. A 65-year-old male consulted for insomnia for two years. Due to work stress, the patient started to wake up at 3 a.m. and experience migraines two years before. The symptoms were aggravated by emotional stimulation. The Western medicine examination did not find any abnormality. He tried Chinese medicine formulas such as Tian Ma Gou Teng Yin and Zhu Sha An Shen Wan without success. He presented with frequent awakenings, thoracic tightness, a bitter taste in mouth, blocked mood, migraines on the left side, frequent sighing, lack of appetite. Stools were slightly dry, the tongue was relatively red and dark with a yellow coating, and the pulse was wiry and slippery. He was prescribed chaihu 30g, huangqin 9g, qing banxia 9g, dangshen 30g, sheng longgu 30g (cooked longer), zhi gancao 9g, sheng muli 30g (cooked longer), fuling 10g, changpu 9g, zhiqiao 9g, zhuru 9g, shengjiang 5 slices and dazao 4 units. He was asked to follow the ancient preparation method of cooking the herbs for 20 minutes, removing the residue and cooking again for 20 minutes. After two weeks of treatment, the patient’s sleep had significantly improved. Case #3. A 40-year-old female consulted for insomnia. Three months before, she had headaches with chill and long sighs. She took anti-cold medication and felt slightly better. At the same time, her mother was hospitalized for acute myocardial infarction, and she was busy taking care of her. After a few days, she started to experience coldness in the back, coldness and pain in the lower abdomen, agitation and severe insomnia. At first, hypnotic drugs helped, but the situation worsened progressively. She was treated with ten bags of herbs that nurture blood, clear heat and calm the spirit without success. She presented with agitation, dizziness and head distension, chest tightness, lack of appetite, hot flushes with alternate coldness and heat, long sighs, dry stools and dark urine. The tongue coating was thin and greasy. She was diagnosed with liver qi stagnation and stagnation of cold fluid

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retention (yin) and treated with CHLMT. She was cured after 18 days of treatment.

4. Gui Zhi Tang (6) 4.1. Original indication There is a wind attack in the taiyang, the yang [pulse] is floating and the yin [pulse] is weak. The floating yang [pulse] means a spontaneous fever and the weak yin [pulse] means a spontaneous sweating. There is aversion to cold, aversion to wind, fever, sneezing and dry vomiting, Gui Zhi Tang is indicated. Shanghan Lun article 12

4.2. Associated patterns Gui Zhi Tang (GZT) is mainly associated with nutritive-protective disharmony (5) and the yang (or protective) being unable to enter the yin (2). GZT is also associated with spleen-stomach disharmony (2), non-­ interaction between heart and kidney (1) and liver-heart disharmony (1). There is the idea that GZT can regulate yinyang globally. GZT can be combined with Zuo Gui Yin, Er Xian Tang, Gan Mai Da Zao Tang, Dang Gui Bu Xue Tang, Huang Lian E Jiao Tang, Ban Xia Xie Xin Tang and Si Ni San. 4.3. Cause There is no consensus on the cause and mechanism of the GZT pattern. Two clinicians associated GZT with a disorder of the circadian cycle due to an irregular schedule as the circulation of the protective qi in the yang during the day and in the yin during the night regulates the wake–sleep circadian cycle. One clinician mentioned yinyang imbalance caused by excessive emotions, lifestyle imbalance, weak constitution and excessive diet. Another clinician mentioned kidney deficiency (also associated with yinyang imbalance) caused by aging, excessive emotions and irregular lifestyle. 4.4. Signs and symptoms There is no consensus either on the signs and symptoms of the GZT pattern in the context of insomnia. One clinician proposed the following 131

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signs and symptoms: insomnia with frequent dreams and difficulty falling asleep, palpitations, breathlessness, dull complexion, agitation, dry mouth, mouth ulcers, red tip of the tongue, thin yellow coating, and thin and rapid pulse. Another clinician mentioned that patients with the GZT pattern do not have a weak constitution and no symptoms other than insomnia and a mild fatigue during the day.

4.5. Ingredients The original ingredients of GZT are guizhi, baishao, shengjiang, dazao and gancao. There was insufficient data to synthesize the doses for these ingredients. One clinician proposed adding herbs such as longgu, muli, cishi and zhenzhumu. 4.6. Analysis Guizhi is pungent-warm and supports the protective; baishao is sourcold and increases the protective. The combination of guizhi and gancao is called ‘pungent and sweet produce yang’, and the combination of baishao and gancao is called ‘sour and sweet produce yin’. Shengjiang helps guizhi to produce yang, and dazao helps baishao to produce yin. The combination of shengjiang and dazao can regulate the spleen and stomach. One clinician explained there are two ways by which GZT can harmonize the nutritive and protective: by producing the nutritive and protective (including by promoting spleen function) and by moving the nutritive and protective (including by soothing the liver). 4.7. Relevant citations The protective qi circulates 25 times in the yin and 25 times in the yang, this differentiates days and nights. Thus, people rise when qi arrives to the yang and stop [their activities] when it arrives to the yin. Lingshu chapter 18

The protective qi circulates in the yang during the day and in the yin during the night. Thus, people fall asleep at the end of the yangqi and wake up at the end of the yinqi. Lingshu chapter 80

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In the context of an external pattern, Gui Zhi Tang liberates the muscles and harmonizes the nutritive and the protective; in the context of an internal pattern, it transforms the qi and harmonizes yin and yang. Jingui Yaolue Xindian

4.8. Clinical cases Case #1. A 45-year-old male teacher consulted for insomnia for five years. Five years before, the patient had a severe common cold and took a formulation containing aspirin, phenacetin and caffeine. The common cold was cured but he was left with insomnia, frequent sweating and aversion to wind. The patient tried blood-nurturing shen-calming, heavy-sedative shen-calming, yin-nurturing heat-clearing and phlegmheat transforming herbal treatments without success. He presented with a slightly yellow complexion, fatigue, light red tongue with a white coating, floating and relaxed pulse (huan) but no other symptoms. He was prescribed guizhi 10g, baishao 10g, shengjiang 6g, zhi gancao 10g, dazao 12 units and two handfuls of fuxiaomai, and he was asked to avoid nicotine and alcohol. The condition improved after three days and he could sleep peacefully after ten days of treatment. Case #2. A 67-year-old male consulted for insomnia with frequent dreams for more than one year. He complained of agitation and insomnia during the night and lack of energy during the day, aversion to wind and abundant sweating, dizziness, lack of appetite, chest tightness. Previous treatments with yin-nurturing, yang-immersing and shen-calming formulas were not very effective. His complexion was dark, pale and dull, his tongue was light red with a thick white coating, and his pulse was wet (ru) and relaxed (huan). He was prescribed guizhi 12g, zhi gancao 12g, baishao 9g, chenpi 9g, fa banxia 20g, shengjiang 3 slices and dazao 15 units. After 20 days of treatment his appetite and sleep had both improved. A follow-up one year later showed he did not relapse.

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5. Gui Zhi Jia Long Gu Mu Li Tang (8) 5.1. Original indication The people who have lost essence present tension in the lower abdomen, coldness in the genital area, vertigo, the pulse is extremely weak, hollow (kou) and slow. This is due to diarrhoea, loss of blood or loss of sperm. The pulses are hollow (kou), stirring (dong), faint (wei) and tight (jin), there is emission in males and erotic dreams in females, Gui Zhi Jia Long Gu Mu Li Tang is indicated. Jingui Yaolue chapter 6

5.2. Associated patterns Gui Zhi Jia Long Gu Mu Li Tang, also called Gui Zhi Long Mu Tang (GZLMT), is associated with disharmony between the nutritive and protective (3) but also deficiency of yin and yang (2), yang deficiency (2) and yang floating at the top (2). GZLMT can be combined with Qian Yang Dan (2), Shi Quan Da Bu Tang (1), Si Ni Tang (1), Gui Pi Tang (1), Huang Lian E Jiao Tang (1), Suan Zao Ren Tang (1) and Xiao Chai Hu Tang (1). 5.3. Cause Information about the cause and mechanism of GZLMT is limited. However, there is a trend to say that GZLMT is caused by exhaustion of resources in the context of a weak constitution, overthinking and overwork. One clinician proposed that GZLMT is appropriate for insomnia caused by external pathogens. 5.4. Signs and symptoms There is no consensus about the signs and symptoms related with GZLMT. One clinician proposed that the indications for GZLMT include a mix of signs of deficiency such as dizziness, tinnitus, palpitations, fatigue, frequent sweating and weak pulse, and signs of floating yang such as dry mouth, agitation and a red tip of the tongue. One clinician mentioned that GZLMT is appropriate for insomnia when there is no significant imbalance of yin and yang (e.g. no strong stagnation or fire). Two clinicians mentioned that GZLMT is appropriate for insomnia comorbid with seminal emission. The clinicians associated GZLMT also with menopause (2) and old age (1).

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5.5. Ingredients The original ingredients of GZLMT are guizhi, baishao, shengjiang, dazao, zhi gancao, longgu and muli. One clinician recommended using sheng longgu and sheng muli to sedate and duan longgu and duan muli to collect and contain. One clinician proposed augmenting the dose of baishao to 30g and adding shanzhuyu for menopausal patients as they often have liver qi stagnation. Another clinician proposed adding banxia to remove phlegm, harmonize the stomach and make the yin and yang communicate. 5.6. Analysis Gui Zhi Tang can harmonize the nutritive and protective. Longgu and muli can collect and immerse the yang. 5.7. Clinical tips Do not use any bitter-cold herbs for this pattern (1). 5.8. Clinical cases Case #1. A 51-year-old female consulted for insomnia related to the discontinuation of her periods one year before. She had frequent dreams, hot flushes, agitation. Her cheeks were red, the palms of her hands were hot and the fingers cold, she felt cold in the genital area as if a wind was blowing, and she had frequent ulcers. Stools were relatively soft, the tongue was light red, the coating thin and white, and the pulse was thin. She previously tried anxiolytics, Western drugs and shen-calming herbal manufactured products. She was prescribed GZLMT combined with Jiao Tai Wan. After seven days of treatment her sleep was significantly improved. Case #2. A 50-year-old female consulted for insomnia for six months. She could sleep three hours per night, had frequent dreams, fatigue, her complexion was pale, her tongue was large and pale with a white coating and her pulse was slow. She previously tried blood-nurturing shen-calming treatment without success and yin-nurturing heat-­ clearing formulas that caused aggravation of the condition. She was prescribed guizhi 10g, baishao 10g, longgu 15g, muli 15g, shengjiang 3 slices, dazao 3 units, fushen 15g and gancao 10g. After five days of

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treatment, her sleep was significantly improved and she had more energy.

6. Gan Mai Da Zao Tang (11) 6.1. Original indication There is organ agitation (zangzao) in females with frequent sadness and desire to cry, as if [the patient] was possessed by a spirit, there is frequent yawning and extension, Gan Mai Da Zao Tang is indicated. Jingui Yaolue chapter 22

6.2. Associated patterns Gan Mai Da Zao Tang (GMDZT) is associated with yin deficiency (5), yet there is no consensus on the organ involved: heart and kidney (1), heart and liver (1), heart (1) and liver and kidney (1). GMDZT is also associated with heart and spleen deficiency (1), liver qi stress (1) and liver fire (1). GMDZT is very often combined with other formulas such as Suan Zao Ren Tang (3), Bai He Di Huang Tang (2) and Xiao Yao San (2). 6.3. Cause The GMDZT pattern is caused by excessive emotions and overwork (6) creating stagnant fire (5), damaging yin and blood (5) and heart qi (2). 6.4. Signs and symptoms The signs and symptoms associated with the GMDZT pattern are sadness and crying (6), agitation (6), anxiety (5), emotional instability like a trance (5), irritability (3), palpitations (3), dizziness (3), hot flushes (3), frequent yawning (2), fatigue (2). It is associated with a red tongue (3) or light red tongue (3), lack of coating (5) and thin and rapid pulse (4). GMDZT is associated with the female gender (2), menopause (4), white-collar workers (1), pregnant women (1) and mental health conditions such as depression and hysteria (2). 6.5. Ingredients The original ingredients of GMDZT are gancao, xiaomai and dazao. However, fuxiaomai is commonly used to replace xiaomai (wheat), which is not commonly available in Chinese medicine pharmacies. GMDZT is 136

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almost never used as a stand-alone formula. Some clinicians add to the basic formula yin-nurturing herbs such as shengdi, baihe, nvzhenzi and hanliancao, heat-clearing herbs such as danpi and zhizi, liver-soothing herbs such as chaihu and yujin, and shen-calming herbs such as suanzaoren and yejiaoteng. The average, minimum and maximum doses of the original ingredients are fuxiaomai 47g (18–120g), gancao 15g (9–30g) and dazao 17g (12–30g).

6.6. Analysis Fuxiaomai, the sovereign herb of the formula, is sweet-cool. It is the light grain of wheat, which, according to the Huangdi Neijing, is the grain of the liver, and it is red, which is the colour of the heart. Therefore, it can nurture the liver and the heart. Dazao and gancao can reinforce the spleen, tonify qi, nurture the heart and nurture yin. Additionally, the formula is sweet, which can relax the liver. 6.7. Clinical tips 1. Fuxiaomai, gancao and dazao must all be used; none can be missing. 2. Fuxiaomai must be used in high doses. 3. GMDZT can relax liver tension, reinforce the spleen, nurture the heart and calm the spirit. 4. GMDZT can be used for a long time without adverse reactions. 5. It must be taken one hour before bedtime. 6. For this pattern, it is not appropriate to tonify heavily or to use bitter-cold herbs excessively.

6.8. Clinical cases Case #1. A 49-year-old female consulted for sleep disturbance for six months. After discontinuation of her periods, the patient started to have trouble falling asleep and frequent awakenings, hot flushes, agitation, irritability, emotional trance, sadness with crying and vaginal dryness. She took Liu Wui Di Huang Wan, Kun Tai capsule, An Shen Bu Nao Ye and qi-tonifying and kidney-tonifying herbs without significant success. The tip and the side of the tongue were red with petechiae, the coating was thin and yellow, and the pulse was wiry, thin and rapid. She was prescribed zhi gancao 6g, fuxiaomai 15g, dazao

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9g, danpi 10g, chao zhizi 10g, chaihu 10g, chao baizhu 10g, danggui 6g, chao baishao 10g, fuling 10g, sheng longgu 30g (cooked longer), sheng muli 30g (cooked longer), danshen 10g, baihe 12g, yejiaoteng 15g and suanzaoren 15g. After five bags, sleep had improved slightly and the hot flushes improved significantly. The formula was changed to a herbal paste and the patient was asked to take one spoonful in the morning and evening with hot water. She was able to sleep normally after this treatment. Case #2. A 28-year-old female consulted for insomnia during her sixth month of pregnancy. She had insomnia, agitation, irritability. She had no other discomfort. The tip of her tongue was red, the coating was thin and white, and her pulse was thin and rapid. She was prescribed gancao 15g, dazao 15g, xiaomai 50g, gouqi 20g, maidong 20g, lugen 30g, suanzaoren 20g, shashen 30g and wuweizi 10g. After two bags, the patient’s sleep was significantly improved, and she was cured after eight further bags.

7. Ban Xia Xie Xin Tang (5) 7.1. Original indication There is vomiting, borborygmus, and gastric distension, Ban Xia Xie Xin Tang is indicated. Jingui Yaolue chapter 17

7.2. Associated patterns Ban Xia Xie Xin Tang (BXXXT) is associated with knots in the middle jiao (1), stomach qi disharmony (1) and liver qi stagnation (1). It can be combined with Gui Zhi Tang (1), Xiao Yao San (1) or Wen Dan Tang (1). 7.3. Cause The core mechanism of the BXXXT pattern is an impairment of spleen ascension and stomach descent (5). This impairment is caused by a weak spleen constitution (2), excessive diet (2), lack of exercise (1) and excessive use of laxative herbs (1). This spleen-stomach disharmony is accompanied with stagnation of phlegm, dampness, food and heat. There are different ways the BXXXT pattern can influence sleep, including a lack 138

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of nutrition of the heart related to spleen weakness, heat disturbing the spirit, and a lack of interaction between heart and kidney due to the spleen-stomach pivot being blocked. One clinician mentioned that BXXXT treated uncontrolled qi ascension and descent related to liver impairment.

7.4. Signs and symptoms BXXXT is indicated by gastointestinal symptoms such as gastric discomfort, abdominal bloating, eructations and acid reflux. The tongue coating is thick and greasy. BXXXT is also associated with insomnia comorbid with diabetes. 7.5. Ingredients The original ingredients of BXXXT are banxia, huangqin, huanglian, ganjiang, renshen, dazao and gancao. In clinical cases, renshen was systematically replaced with dangshen, and dazao was sometimes removed. Fa banxia (2) or unspecified banxia (4) were used. Zhi gancao (2) and sheng gancao (3) were both used. The average, minimum and maximum doses used in clinical cases are: banxia 13g (9–15g), dangshen 14g (10–30g), huangqin 10g (6–15g), huanglian 7g (5–10g), ganjiang 9g (6–10g) and gancao 12g (6–20g). 7.6. Analysis Banxia can open the stagnation and disperse the knots. Renshen, dazao and gancao help the spleen to elevate the clear. Huangqin and huan­glian drain the heat and help the stomach to move the turbid down. Ganjiang can support banxia in dispersing qi, reduce the toxicity of banxia and prevent huangqin and huanglian from harming the spleen and stomach. The combination of banxia and ganjiang with huangqin and huanglian is excellent to regulate qi movements as it can ‘open with pungent [herbs] and descend with bitter [herbs]’. 7.7. Modifications In the case of spleen qi deficiency, add baizhu and huangqi. In the case of spleen and stomach yin deficiency, add baizhu, fuling, danggui, yuanzhi, suanzaoren and longyanrou. In the case of phlegm-heat, add yujin, zhizi, changpu, yuanzhi and zhuru. In the case of stomach qi inversion with food stagnation, add jiao shanzha, jiao shenqu, jiao maiya, chao jineijin, zhishi, houpo and chenpi. 139

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7.8. Clinical cases Case #1. A 38-year-old male consulted for gastric bloating and insomnia for five years. Five years before, the patient started to experience gastric bloating, lack of appetite, acid reflux, agitation and insomnia due to excessive consumption of cold food. He took Bao He Wan, Shan Zha Wan and domperidone, but the symptoms were coming and going. Six months previously, due to work stress, the patient started to have agitation, trouble falling asleep, frequent dreams and waking up easily. Sedatives such as valium were effective, but he relapsed after discontinuation. As he was worried about side effects, the patient consulted Chinese medicine. He presented with fatigue, lack of appetite, abdominal bloating, gastric bloating, eructations, acid reflux and loose stools. His tongue was pale with a white and yellow coating, slightly greasy, and his pulse was wiry and relaxed (huan). He was prescribed BXXXT: banxia 15g, ganjiang 9g, huangqin 6g, huanglian 6g, dangshen 12g, gancao 6g, dazao 6 units, longgu 30g and muli 30g. After five bags, his sleep and appetite had improved, and the abdominal bloating was reduced. After seven more bags, the symptoms disappeared.

8. Interpretation and Discussion Compared with other formulas, classical formulas tend to regulate the body in a more vague and global manner. Apart from CHLMT, they do not specifically ‘drain liver fire’, ‘transform phlegm-heat’ or ‘tonify heart and spleen’. Instead, they tend to regulate the yin and yang, the protective and the nutritive, and the shaoyang pivot, and they regulate qi movements in a global manner. For this reason, their indications are not as specific as for other formulas and their use is much more individualized (i.e. dependent on the perspective of the clinician). Although classical formulas do not target a specific ‘pattern’, they have a tendency to regulate the liver and the spleen. Formulas such as XCHT and CHLMT, which are known to regulate the liver, include spleen-regulating ingredients such as renshen, shengjiang and dazao. GZT, which is known to regulate the spleen and stomach, includes baishao which regulates the liver. One clinician even used BXXXT, which is clearly focused on the spleen and stomach, as a liver-soothing formula. SZRT is typical of this tendency, with suanzaoren and c­ huanxiong to regulate the liver and fuling and gancao to regulate the spleen. As some of

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these formulas (especially SZRT, XCHT and, to a lesser extent, CHLMT) can be used on a disease basis (i.e. regardless of the pattern), this strengthens the idea that liver dysregulation is the core mechanism of insomnia (and spleen-stomach disharmony a general underlying factor). Classical formulas have a few other specific characteristics. They tend to have fewer ingredients than other formulas. For this reason, they are very often combined with other classical formulas or non-classical formulas. This is especially true for GMDZT, which is rarely used as a stand-alone treatment. Another point, also related to the low number of ingredients, is that some clinicians tend to use high doses. For example, in SZRT, suanzaoren can be used up to 180g, and in CHLMT, chaihu can be used up to 30g. This is in line with the original text of the Shanghan Lun, in which Zhang Zhongjing systematically used high doses.

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Chapter 9

Disease-Based Treatment with Chinese Herbal Medicine In Chinese herbal medicine, clinical diagnosis can use a pattern-­ differentiation or a disease-differentiation approach. In the ­pattern-­differentiation approach, a global clinical phenotype is determined through the analysis of signs and symptoms (SSs). Multiple individualized treatments can be proposed for the same disease (e.g. insomnia), according to the clinical phenotype. Pattern differentiation is considered the more effective approach but is difficult to implement due to the variations of pattern definitions and classifications. The pattern differentiation is also more easily subject to misdiagnosis due to the similarity of different patterns. In contrast, the disease-differentiation approach proposes one standardized formula for a particular disease (e.g. insomnia) regardless of the SSs of the patient. This approach, which has been recorded by the Prescriptions for Fifty-Two Diseases from the Han dynasty, may be the oldest diagnostic approach in Chinese medicine and has been consistently used until the present day. The guidelines for the treatment of insomnia do not, however, propose treatment protocols based on disease differentiation, possibly because standardized treatments are considered to reflect poor clinical reasoning. As a result, there is a lack of documented protocols to guide consistent practice despite the widespread use of disease differentiation in the clinic. This section categorizes the protocols based on disease differentiation (not on clusters of signs and symptoms) as reported in clinical experience reports. We investigated the reason why clinicians found it appropriate to use a single formula to treat insomnia.

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1. Overview Sixty-one clinical experience reports provided a single-formula protocol for the treatment of insomnia with Chinese herbal medicine. These 61 main formulas were composed of 705 herbs in total (Figure 9.1). The most commonly recommended herbs (with number of formulas in brackets) are gancao (43), suanzaoren (43), fuling (30), chaihu (26), chuanxiong (25), shouwuteng (21), longgu (20), yuanzhi (20), baishao (19) and banxia (19). Apart from the ingredients of Suan Zao Ren Tang, we can observe spirit-calming herbs (shouwuteng, longgu, yuanzhi), ­liver-draining herbs (chaihu, shaoyao) and banxia. We can point out that some clinicians consider chaihu, baishao and banxia to be spirit-calming herbs (see Chapter 14). xiakucao huangbai fuxiaomai shudihuang

fuling chaihu maidong

maiya

taoren gouqizi

shengdi cebaiye

shigao

houpo

hehuanpi fushen huangqi

dannanxing ezhu

rougui

suanzaoren zhimu longgu yuanzhi muli gancao banxia dilong

baiziren zhuru

zhizi

cangzhu

sharen

guizhi hupo nvhanlian niuxi chantui

changpu

honghua

zhuling

chixiaodou dengxincao

zhuyexin

chenpi

lianqiao

gusuibu longchi peilan yizhiren qingpi tianma xiyangshen

bohe

zhishi

dahuang

ejiao

yejiaoteng juhua

yujin

baishao

shanzhuyu

danggui zexie

dangshen

gualou tubiechong

yinyanghuo

shenqu

cishi

longyanrou yinchen jiegeng

huangqin

baihe

nvzhenzi

yiyiren

chuanxiong tianzhuhuang sanleng

wuweizi

zhenzhumu danshen foshou xiangfu shengjiang gegen taizishen shengma

cijili

chenxiang shanyao

xiaomai

dandouchi

muxiang

chishao

huanglian

renshen

lianzixin

yuanhu sangye sanqi

gouteng

zhiqiao

danpi

zibeichi

baizhu

hehuanhua

shanzha

dazao

Figure 9.1. Herbs of the main formulas The size of the word is proportional to the number of formulas in which the herb is present.

2. Main formula In the disease approach, a main formula is used regardless of the SSs of the patient and can be modified according to the pattern. The 61 main

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formulas we identified were divided into four categories – ‘Shen-Calming’, ‘Big and Diverse’, ‘Liver-Draining’ and ‘Suan Zao Ren Tang’. These four categories included 51 formulas (84% of the total), among which four formulas were part of both the ‘Liver-Draining’ and ‘Big and Diverse’ categories.

2.1. Shen-Calming formulas Some clinicians gather different kinds of herbs that have a shen-calming effect into the same formula as a treatment of insomnia. This category is the largest of the disease-based approach, including 23 formulas. It was defined as formulas having at least 50% of herbs with shen-calming effects in the composition. The nine core herbs of these formulas are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

suanzaoren (83%) gancao (48%) yejiaoteng (44%) longgu (44%) muli (44%) fushen (39%) baiziren (39%) fuling (35%) yuanzhi (35%).

2.2. Big and Diverse formulas Some clinicians combined herbs with different effects such as yin-­ nurturing, liver-draining, phlegm-transforming and, of course, ­spirit-calming into the same formula. These formulas usually have a large number of ingredients compared with the other categories and we called them ‘Big and Diverse’ formulas. We included in this category 15 formulas that have at least 13 ingredients and have ingredients from at least eight herb categories. The 17 core herbs of this category are: 1. 2. 3. 4. 5. 6. 7.

suanzaoren (80%) gancao (67%) yuanzhi (67%) chaihu (60%) fuling (60%) chuanxiong (53%) yejiaoteng (53%)

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8. baishao (53%) 9. longgu (47%) 10. zhizi (40%) 11. dangshen (40%) 12. banxia (40%) 13. muli (40%) 14. hehuanpi (40%) 15. fushen (33%) 16. changpu (33%) 17. baiziren (33%).

2.3. Liver-Draining formulas Many clinicians use chaihu-type formulas as a main formula for the treatment of insomnia. As these formulas are usually considered to be liver-draining (among other effects), we called them ‘Liver-Draining’ formulas. We included in this category ten formulas in which the pattern name was ‘liver stagnation’ or in which the formula name was either ‘Xiao Chai Hu Tang’ or ‘Xiao Yao San’ (including modified versions). The nine core herbs of this category are: 1. 2. 3. 4. 5. 6. 7. 8. 9.

chaihu (90%) gancao (80%) banxia (70%) shengjiang (60%) huangqin (60%) fuling (50%) dangshen (50%) dazao (40%) baizhu (40%).

2.4. Suan Zao Ren Tang formulas Suan Zao Ren Tang was by far the most commonly proposed individual formula among disease-based main formulas. We defined Suan Zao Ren Tang formulas as formulas in which at least three ingredients from Suan Zao Ren Tang are present and the ingredients of Suan Zao Ren Tang compose at least 50% of the whole formula. This allowed the exclusion of formulas in which the use of Suan Zao Ren Tang’s ingredients was accidental. Seven formulas were included in this category. The six core herbs of this category are: 145

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1. 2. 3. 4. 5. 6.

suanzaoren (100%) gancao (100%) chuanxiong (100%) zhimu (100%) fuling (71%) fushen (29%).

2.5. Unclassified formulas We were not able to find any specificity or rule for ten formulas. These ten formulas were: • • • • • • • • • •

Xue Fu Zhu Yu Tang (1) Wen Dan Tang (1) Tiao Qi Huo Xue Tang (1) Jie Yu Yi Qi Yang Xue Tang (1) Huang Lian Wen Dan Tang (1) Ji Ben Fang (1) Dang Gui Liu Huang Tang (1) Gui Zhi Tang (1) An Mian Tang (1) San Qing An Mian Tang (1).

3. Modification according to the pattern In most cases, the clinicians proposed a modification of the disease-based main formula according to the pattern. We identified 162 pattern-based modifications, among which 154 were finally clustered into six categories or ‘patterns’ (Table 9.1), leaving eight formulas unclassified. Depending on the parameters of the cluster analysis, different classifications were also possible. The main differences between the final categorization and the other pre-selected categorizations are the presence or not of ‘Heart Fire’, ‘Blood Deficiency’, ‘Hyperactive Liver Yang’, ‘Non-Interaction Between Heart and Kidney’, ‘Kidney Deficiency’ and ‘Food Accumulation’ clusters.

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Table 9.1. Pattern relevant to formula modification with associated high-sensitivity SSs and core herbs Pattern (NF)

High-sensitivity SSs (Sn, Sp)

Core herbs (Sn, Sp)

Liver Stagnation (15)

Stress and irritability (36%, 22%) Agitation (27%, 16%) Diarrhoea (18%, 40%)

Chaihu (53%, 32%) Yujin (40%, 43%) Xiangfu (33%, 42%) Danggui (13%, 9%)

Phlegm-Heat (43)

Agitation (28, 37) Slimy fur (24, 67) Lack of appetite (24, 43) Stuffy chest (24, 43)

Banxia (21, 64) Huanglian (21, 39) Fuling (16, 78) Shengdi (16, 58)

Liver Fire (21)

Stress and irritability (64, 39) Bitter taste in mouth (55, 50) Wiry pulse (36, 29) Headaches (27, 60)

Zhizi (48, 56) Longdancao (24, 56) Huangqin (19, 36)

Hyperactive Liver Yang (6)

Eye redness (67, 40) Vertigo (67, 25) Wiry pulse (67, 14) Dry stool (33, 50) Head confusion (33, 50)

Longgu (50, 43) Tianma (33, 100) Gouteng (33, 100) Niuxi (33, 67)

Heart-Spleen Deficiency (49)

Frequent awakenings (22, 86) Palpitations (22, 50) Fatigue (22, 46)

Huangqi (18, 60) Baizhu (16, 47) Danggui (16, 36) Huanglian (10, 22)

Non-Interaction Between Heart and Kidney (14)

Dizziness (33, 33) Tinnitus (33, 33)

Baishao (43, 46) Shudihuang (36, 36) Danggui (36, 23) Gouqizi (21, 50) Baizhu (21, 18)

NF = number of formulas; Sn = sensitivity; Sp = specificity (percentage of formulas with this herb belonging to this pattern and not to other patterns).

4. Interpretation and discussion Pattern differentiation is usually considered the best diagnostic and therapeutic approach. In this context, it can be surprising that so many clinicians propose a disease-based approach. What, then, is the rationale behind this use? We can obviously only speculate on the rationale behind the disease approach, which may include the following.

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4.1. Calming the shen Shen-calming herbs, which by definition help people to sleep better, are used consistently by all clinicians for insomnia regardless of the pattern. However, the mainstream position is that shen-calming herbs should not be overused when treating insomnia (see Chapter 14, Shen-Calming Herbs). Nevertheless, using a shen-calming formula as the main formula in the disease approach is not surprising and shows that a symptomatic approach to the treatment of insomnia can be a therapeutic option. Indeed, 70% of the most common herbs in the disease approach are shen-calming herbs and 100% of them have shen-calming effects. This rationale not only explains the Shen-Calming Formulas category, but it is also visible in other categories of disease-based treatment. Suan Zao Ren Tang has two herbs with shen-calming effects – suanzaoren and fuling. The majority of the core herbs of the Big and Diverse formulas are shen-calming herbs. Shen-calming herbs were also used consistently in every pattern of the pattern-based treatment. The only question is really what ratio of shen-calming herbs we want to use. Most clinicians use around 15% of shen-calming herbs in the pattern-based approach, but this ratio can exceed 50% in the Shen-Calming formulas category. 4.2. Targeting the core mechanism In Chapter 6 we discussed the three pathological systems of insomnia. The core mechanism of the largest system is liver qi stagnation, which is associated with liver fire and blood deficiency and can lead to phlegmheat and blood stasis (see Chapter 6). Formulas such as Xiao Chai Hu Tang and Xiao Yao San target this core mechanism and can be adapted if the patient presents other patterns such as phlegm-heat, liver fire or spleen deficiency. Interestingly, liver qi stagnation is a minor pattern in the pattern-based approach but is a major aspect in the disease approach, not only for Liver-Draining formulas but also in the Big and Diverse formulas, and to a certain extent in Suan Zao Ren Tang formulas. This shows that although insomnia patients rarely present with a typical pattern of Liver Qi Stagnation, liver qi stagnation is omnipresent in the pathological mechanism of insomnia and needs to be addressed. Interestingly, yin-nurturing, heat-clearing herbs and qi/blood tonics are relatively absent from the disease-based formulas. This may further indicate the prevalent position of the liver stagnation system over the yin deficiency with fire system and the heart and spleen deficiency 148

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system. In this regard, yin-nurturing and heat-clearing formulas and qi/blood-tonifying formulas may not be appropriate to use regardless of the pattern and should be used only on the basis of the pattern.

4.3. Using a flexible formula In the cluster analysis of the pattern-based formulas (see Chapter 6), we found that some formulas consistently generate a pattern regardless of the parameters of the analysis and some other formulas jump from one pattern to another depending on the parameters of the analysis. For example, Gui Pi Tang consistently leads the ‘Heart and Spleen Deficiency’ pattern and ‘Xue Fu Zhu Yu Tang’ can almost always form a cluster of its own. On the other hand, Suan Zao Ren Tang would jump from the ‘Yin Deficiency with Fire’ pattern to the ‘Classical Formulas’ pattern or the ‘Liver Stagnation’ pattern. The reason is that, in terms of composition, Suan Zao Ren Tang does not have a clear direction. It is composed of one shen-calming herb, one blood-moving herb, one diuretic herb, one heat-clearing herb and one tonifying herb. Although Suan Zao Ren Tang is sometimes considered to be indicated for ‘Liver Blood Deficiency’, it is not clearly oriented toward this pattern. This makes Suan Zao Ren Tang an ideal formula in the disease-based approach as it can be easily adapted to the situation of the patient. It can link the liver stagnation system with the yin deficiency with fire system, and even, arguably, the heart and spleen deficiency system. This flexibility is not only observed in Suan Zao Ren Tang but also to some extent in Xiao Chai Hu Tang and Xiao Yao San, which have many famous modifications such as Chai Hu Gui Zhi Tang, Chai Qin Wen Dan Tang, Dan Zhi Xiao Yan San, Hei Xiao Yao San, etc. It shows that these formulas are appropriate in the disease-based approach as they can be relatively easily adapted to the specific condition of the patient. 4.4. Covering all pathological aspects The main formula of the Big and Diverse group has on average 17 herbs, which is twice as many as the average number of herbs in the main formula of the pattern-based approach. They include diverse types of herbs such as yin-nurturing, blood-nurturing, liver-draining, fire-draining, shen-calming, phlegm-transforming, etc. The reason for mixing such different herbs in the formula is unclear. It may be that clinicians are trying to catch all the possible mechanisms of insomnia at the same time and ensure that they cover every single aspect of the condition. 149

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It is not uncommon to have patients manifesting multiple patterns at the same time. Moreover, as clinical diagnostic methods are always limited, not being able to identify a certain pattern does not mean that the patient does not have this particular pattern. In this context, being conservative and trying to cover a pathological area as large as possible somewhat makes sense.

4.5. Personal understanding of the core mechanism of insomnia Clinicians understand clinical phenomena through their own experience and beliefs. Because of these biases, they may think that the core mechanism of insomnia is either phlegm-heat, blood stasis or yin deficiency with fire. As this is not a widespread position, only one or two formulas can be grouped under the same mechanism or pattern, which is not enough to create an identifiable group of formulas. This is why these formulas remained unclassified. The only mechanism that could reflect a shared understanding of the core mechanism of insomnia is liver stagnation, as ten liver-draining formulas were identified in the disease-based approach. 4.6. Conclusion According to this chapter, ‘disease differentiation’ is not merely a symptomatic approach based on Western medicine pathology and pharmacology. It may reflect the attempt of the clinician to grasp the core mechanism of insomnia, using a flexible formula that can be easily modified according to the patient or that tries to cover as many aspects of the pathological mechanism as possible. Even though it may not be the most effective approach, it may be the best choice when pattern diagnosis is not clear or not available. In any case, investigating the rationale behind the use of disease-based treatment can deepen our understanding of the condition and provide additional tools to the therapeutic palette.

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Chapter 10

Treatment Adaptation According to the Person, the Season and the Location In Chinese medicine, treatments can be adapted according to the features of the person, according to the season and according to location. This is called the ‘triple adaptation (sanyin zhiyi)’ principle. In this chapter, we present the specific methods for the triple adaptation relevant to the treatment of insomnia.

1. Treatment adaptation according to the person The treatment can be adapted according to the age, sex, constitution, personality and comorbidities of the patient.

1.1. Treatment adaptation according to the age of the person In terms of age, generally speaking, younger people are considered to have excess patterns (4) while older adults are considered to have deficiency patterns (4). We can identify three age categories: children, young and mature age adults, and older adults. 1.1.1. Features of insomnia in children Children are considered to have a weak constitution as their body is not fully developed (2). They have a weak spleen (3) which can lead to food stagnation (3), manifested by crying, panicking or teeth-grinding at night (1). For school-age children, stress from study requirements (2) can lead to liver stagnation (3) and liver fire (1). When treating very young children, the clinician should recommend not feeding the baby at night in order to avoid milk or food stagnation (1) and not comforting the child

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every time he or she wakes up to avoid conditioning (1). Mild and neutral herbs should be used instead of high doses of bitter-cold herbs (1). An eight-year-old girl consulted for disturbed sleep for more than one month. She was agitated and ground her teeth during her sleep, had a lack of appetite and did not like to drink; her stools were dry and her urine slightly dark. The physical examination was normal. Her tongue was red with a white coating. She was prescribed a granule formula with chaihu, shengdi, danggui, chuanxiong, baishao, bohe, chao baizhu, gouteng, chao maiya, chao guya, jineijin, baimaogen, duan muli. After 14 bags, her sleep had improved. 1.1.2. Features of insomnia in young and mature age adults Lifestyle factors are the main causes of insomnia in young and mature age adults, including stress from work, studies and family responsibilities (4), overthinking (2), excessive diet (3), sleep deprivation (2) and lack of exercise (1). These factors provoke liver stagnation (7) and spleen deficiency (2), which can result in fire (3) and phlegm-heat (2). The duration of the disease is relatively short for young and mature age adults (2). 1.1.3. Features of insomnia in older adults Progressive consumption of vital substances due to aging is the main cause of insomnia in older adults (7). Along with spleen deficiency (2), it can cause a deficiency in the blood-essence of the liver and the kidney (10), qi-blood deficiency (5) and also yang deficiency (4). Aging can also cause blood stasis (4) in relation to arteriosclerosis (2). In addition to aging, emotions are also an important cause of insomnia in older adults (3), causing yin deficiency and excess of fire (4). The kidney yin of young adults is strong and abundant; therefore, their sleep is deep and long. The kidney yin of older adults is deficient and weak; therefore, their sleep is light and they wake up easily. Fengshi Jinnang

An important feature of insomnia in older adults is the complexity of the pathological mechanism (3) with deficiency present together with phlegm, blood stasis and fire. This is partly due to the high number of functional (e.g. anxiety, depression) and organic (e.g. hypertension,

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cardiovascular diseases, diabetes) comorbidities (2). When the pathological mechanism is complex, the clinician should ‘grab the main pattern’ (i.e. identify the core pathological mechanism) and treat it with a single formula, adding only a few herbs to treat the secondary patterns (1). The formula should be kept below 12 ingredients and not be changed until there is significant improvement (1). The treatment should be taken for a long time, using manufactured products or diet therapy if necessary (1). In the case of blood stasis, the clinician should be careful about not using too many or too strong blood-­ activating herbs (1) and instead use a combination of blood-activating and blood-nurturing herbs such as danshen, danggui, yimucao, chuanxiong, sanqi and chishao (1). As there is a risk of bleeding in older adults, sanqi can also be used to prevent this (1). Finally, because of the constitutional weakness of older adults, it is important to strengthen their spleen (1). The data was insufficient to conduct quantitative analyses for children and young/mature adults specifically. We were able to conduct a quantitative analysis for older adults, though. In terms of herb categories, compared with the treatment of the general insomnia population, the 23 formulas used specifically for insomnia in older adults included more: • • • • •

yang-tonifying herbs (+175%) collecting and consolidating herbs (+146%) interior-warming herbs (+130%) liver-calming and wind-extinguishing herbs (+89%) spirit-calming herbs (+16%).

They included less: • • • •

food-transforming herbs (–100%) qi-moving herbs (–77%) phlegm-transforming and anti-coughing herbs (–27%) heat-clearing herbs (–12%).

The yang of older adults is deficient and they cannot sleep. Zhengzhi Yaojue

In terms of individual herbs, the formulas for insomnia in older adults included more:

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• • • • • • • • • • • • • • • • • • • • •

jiangcan (+3695%) daizheshi (+743%) yinyanghuo (+743%) juhua (+623%) fuxiaomai (+462%) tianma (+406%) shanyao (+392%) shanzhuyu (+322%) fuzi (+289%) huangbai (+216%) ganjiang (+198%) fushen (+174%) guizhi (+174%) gouqizi (+171%) hehuanpi (+141%) shudihuang (+120%) danpi (+117%) yejiaoteng (+70%) longgu (+61%) muli (+60%) changpu (+53%).

The formulas for insomnia in older adults included less: • • • • • • • • • • • • • • •

zhishi (–100%) renshen (–100%) zhuru (–100%) zhiqiao (–100%) muxiang (–100%) longchi (–100%) shenqu (–100%) chenpi (–79%) huanglian (–64%) shengjiang (–60%) maidong (–57%) zhizi (–57%) fuling (–45%) danggui (–44%) baizhu (–41%)

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• chaihu (–38%) • banxia (–34%) • yuanzhi (–31%). The quantitative analysis shows that kidney tonics and warm herbs are used more commonly in older adults. It shows that kidney deficiency and yang deficiency are more common in older adults. As this can lead to a surge of liver yang or deficiency fire, heavy herbs such as daizheshi, longgu and muli and liver-inhibiting herbs such as tianma and gouteng are also more common. Surprisingly, blood-moving herbs are not more commonly used for older adults. This may be due to the fact that blood stasis is a major pattern of insomnia, which means that blood-moving herbs are commonly used in any population with insomnia. The qi and blood of young adults is abundant, their muscles smooth, their qi channel free, the circulation of nutritive and protective is normal, therefore they are shrewd during the day and sleep at night. The qi and blood of older adults is deficient, their muscles withered, their qi channel blocked, the qi of the five organs fight each other, the nutritive qi is lacking and the protective qi attacks internally, therefore they are not shrewd during the day and do not sleep at night. Lingshu chapter 18

Eliminating herbs (including heat-clearing, phlegm-transforming, qi-moving and food-transforming herbs) are used less commonly in older adults. This shows a tendency towards tonifying instead of draining, moving and transforming. Overall, older adults more commonly follow a path of the yin deficiency and fire system of insomnia instead of the mainstream liver stagnation system (see Chapter 6).

1.2. Treatment adaptation according to the sex of the person Insomnia in females is associated with qi stagnation (3), blood deficiency (2) and blood stasis (1), while insomnia in males is associated with liver fire (1). Pregnancy-related insomnia, which is specific to females, is associated with yin-blood concentrated in the bottom which causes an excess of heart fire (1). The characteristics of male and female insomnia are rarely described, but many clinicians focus on menopause-related insomnia and its characteristics. 155

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1.2.1. Features of insomnia in menopausal women When women are…49 years old the Ren vessel and Chong vessel are deficient, the Tiangui is exhausted, the earth pathway is blocked, therefore the physical body is damaged and there is no child. Suwen chapter 1

The main pathological factor of insomnia in menopausal women is liver and kidney yin deficiency (11) provoking fire (7). This is largely due to the consumption of essence and blood because women undergo menstruation, pregnancy, childbirth and breast-feeding (3). Liver stagnation (5) creating fire (2) is also a major mechanism. This is due to the stress menopausal women undergo in relation to longing for the years gone and the burden of social and familial roles (3). One clinician pointed out that kidney yang and kidney yin deficiency are not common and that most menopausal women with insomnia have heart deficiency and liver congested fire (1). Another clinician pointed out that many women had the phlegm-heat pattern, partly due to the fact that menopausal women are excessively treated with yin-nurturing herbs (1). Senile vaginitis, recurrent urinary tract infection and their treatment with heat-clearing dampness-draining herbs can also aggravate insomnia (1). In this case, yin-nurturing and fire-draining should be conducted (1). Finally, gouqizi, nvzhenzi and ziheche can be used in the case of low oestrogen levels (1). 1.2.2. Treatment of insomnia in menopausal women The 53 formulas used specifically for insomnia in menopausal women were compared with the treatment of the general insomnia population. In terms of herb categories, these formulas included more: • • • • • •

yang-tonifying herbs (+222%) yin-tonifying herbs (+109%) collecting and consolidating herbs (+105%) liver-calming and wind-extinguishing herbs (+49%) blood-tonifying herbs (+23%) heat-clearing herbs (+10%).

They included less:

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• • • • •

food-transforming herbs (–100%) water-draining herbs (–41%) surface-liberating herbs (–38%) phlegm-transforming and anti-coughing herbs (–34%) qi-tonifying herbs (–23%).

In terms of individual herbs, the formulas for insomnia in menopausal women included more: • • • • • • • • • • • • • • • • • • • • • •

lv’emei (+3609%) zibeichi (+1754%) meiguihua (+1291%) guijia (+1225%) bajitian (+1136%) digupi (+1013%) yinyanghuo (+518%) lianzixin (+406%) xiaomai (+364%) huangbai (+248%) jizihuang (+165%) baihe (+158%) hehuanpi (+135%) shanzhuyu (+121%) danpi (+112%) ejiao (+100%) shudihuang (+88%) yujin (+85%) yejiaoteng (+78%) zhimu (+65%) baishao (+44%) huanglian (+33%).

The formulas for insomnia in menopausal women included less: • • • • •

longdancao (–100%) shenqu (–100%) renshen (–77%) shengjiang (–71%) zhiqiao (–67%)

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• • • • • • • • • • • • •

xiangfu (–67%) muxiang (–65%) huangqi (–56%) banxia (–52%) dangshen (–49%) wuweizi (–47%) huangqin (–38%) yuanzhi (–36%) chuanxiong (–29%) fuling (–27%) chaihu (–18%) danggui (–18%) suanzaoren (–16%).

The quantitative analysis shows that the adaptation of the treatment to menopausal women shares common features with the treatment of older adults. In both cases, the kidneys are tonified, the liver is inhibited and the excessive yang is brought down. Phlegm-transforming, food-transforming and dry qi-moving herbs are used less commonly. However, a few differences between the treatment of menopausal women and the treatment of older adults can be observed. Yang-andessence tonics such as bajitian are used in both cases, but warm and dispersing herbs such as fuzi, ganjiang and guizhi are used only for older adults. There is a more pronounced tendency toward yin deficiency and fire in menopausal women, with the use of herbs such as digupi, huangbai and zhimu. Qi stagnation is common in both the general population and menopausal women, but is treated with softer herbs such as lv’emei, meiguihua and hehuanpi instead of xiangfu, chuanxiong and chaihu.

1.3. Treatment according to the constitution of the person The constitution is defined by long-term psychological characteristics of one person. People with yin deficiency or qi stagnation constitutions are more vulnerable to insomnia (1). People with different constitutions are also susceptible to different patterns of insomnia. For example, people with liver deficiency are susceptible to the kidney deficiency pattern (1), people with yang deficiency are susceptible to the spleen deficiency pattern (1), people with a fire-type constitution – defined as being stressed, irritable and explosive – are prone to liver and heart fire (2), and people with a wood-type 158

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constitution are prone to the heart and spleen deficiency pattern (1). Obese and depressed women are prone to stagnation and phlegm-fire (1). People with a banxia constitution – defined as being perfectionist, doubtful, tense, easily panicked and presenting various autonomous system symptoms such as dizziness, palpitations, vomiting or numbness – are prone to the phlegm-heat pattern (1). When the symptoms are severe, one should focus on the symptoms, but when the symptoms are mild, the treatment should be focused on the constitution (1). The pattern and the constitution should both be taken into account. If they are aligned, the dose of the herbs corresponding to the constitution should be increased, but if they are opposed, the treatment should be adjusted accordingly (1). After remission, it is better to continue to regulate the constitution in order to prevent relapse (2). Examples of treatment for the constitution after remission are shown in Table 10.1. Table 10.1. Treatment before and after remission according to the pattern or the constitution Constitution

Pattern

Pattern-specific treatment

Constitutionspecific treatment

Qi deficiency

Heart-SpleenGallbladder Deficiency

An Shen Ding Zhi Wan and Gui Pi Tang

Si Jun Zi Tang

Yang deficiency

Spleen and Kidney Deficiency

Gui Fu Di Huang Wan

Shen Qi Wan

Yin deficiency

Yin Deficiency and Excessive Fire

Tian Wang Bu Xin Dan

Liu Wei Di Huang Wan

Blood stasis

Qi Stagnation and Blood Stasis

Xue Fu Zhu Yu Tang

Taoren, danggui and cloud ear fungus

Qi stagnation

Liver Stagnation Creating Fire

Long Dan Xie Gan Tang or Dan Zhi Xiao Yao San

Xiao Yao Wan

1.4. Personality of the person Some personality traits such as sensitivity, introversion, emotional instability, being conservative or stubborn traits all increase vulnerability to insomnia (1). One of the reasons is that being sensitive and not adaptive enough increases the probability of external stimuli provoking emotions (1). More generally, different personality traits act as a ‘ground’ for certain types of insomnia. For example, timid and cowardly people 159

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are subject to panic, which can lead to panic-type insomnia (1). This type of insomnia has to be treated with heavy-sedative spirit-calming herbs (1). More common patterns and their ‘ground’ personality traits are summarized in Table 10.2. Table 10.2. Common patterns of insomnia and their ‘ground’ personality traits Pattern

Personality trait

Heart and Spleen Deficiency

Introverted and prone to thorough consideration (1)

Heart and Gallbladder Deficiency

Introverted, easily frightened and timid (1)

Liver Qi Stagnation

Introverted (3), irritable (2), depressed (2) and sentimental (1)

Heart and Liver Fire

Irritable (1)

Congestion of Phlegm and Qi

Suspicious (1) and worried (1)

1.5. Comorbidities of the person The complex question of comorbidities is covered in Chapter 12.

2. Treatment adaptation according to season The treatment itself is generally not based on the season. However, the formula can be adapted according to the season or climate. For example, rainy and humid weather in summer can provoke spleen dampness, which is manifested by body heaviness, fatigue, nausea, etc. (1). In this case, huoxiang and peilan can be added to the formula (1). In autumn, the lung-metal is excessive and inhibits the liver-wood; therefore, baibu should be used to moisten the lung, nurture the yin and soften the liver (1). The five movements and six qi (wuyun liuqi) can also be taken into consideration. The five movements and six qi system is a system of correspondence between the time and global climatic tendencies according to the five movements (i.e. wood, fire, earth, metal and water) and related climates (i.e. wind, cold, summer-heat, dampness, dryness and heat). For example, the climatic characteristics of 2016 were an excess of fire and the inhibition of the earth by water (1). Therefore, in 2016 insomnia needed to be treated with Bai Le Mian capsules which nurture the yin, clarify heat and drain excessive dampness (1).

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3. Treatment adaptation according to location According to the clinicians, location can influence people’s constitution in three ways: climate, local food and local culture. For example, a humid climate tends to create dampness, high-fat and sweet local food creates dampness, and a fast-paced culture tends to create liver congestion. Sometimes the combination of climatic and cultural factors creates the pathological mechanism – for example, a humid climate with spicy food and a hot climate with high-fat food can both create dampness-heat. The location can be considered in three ways: 1. direct cause of a pathological mechanism (i.e. a pattern) 2. increased vulnerability of the person to a certain pattern 3. background factor that must be taken into consideration (e.g. adding qi-moving herbs such as muxiang and zisugeng when treating qi and blood deficiency in a patient from the humid South-of-Mountains region). The influence of the location on the pathological mechanism of insomnia is shown in Table 10.3. Table 10.3. Local factors and patterns caused in different regions Region

Local factor

Pattern

South-of-Mountains (Lingnan) – roughly Guangdong and Guangxi provinces

Humid and hot climate (4), sweet food (1) and cold tea (1), fast-paced and stressful lifestyle (1)

Phlegm-heat (4), dampness (2), spleen deficiency (1), liver congested fire (1) and yin deficiency (1)

Sichuan

Humid climate (1), high-fat and spicy food (1)

Phlegm-dampness (1)

Hunan

Humid climate (1) and spicy food (1)

Phlegm-heat (1)

Xinjiang

Hot and dry climate (1) and high-fat, sweet, meat-rich and roasted food (1)

Dampness-heat (1)

Yunnan

Cold and humid climate (1)

Cold-dampness (1)

4. Interpretation and discussion We can see from the above that the characteristics of the patient, the season and the location have an influence on the clinical reasoning of

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the clinicians yet do not determine the main diagnosis and the main treatment for insomnia. The main treatment is usually pattern-based (on the basis of groups of signs and symptoms) or disease-based (on the basis of the pathological characteristics of insomnia). The patient’s characteristics, the season and the location can help the clinician to understand the pathological mechanism of insomnia, which can influence pattern diagnosis and the subsequent treatment. For example, if the patient is a menopausal woman, the gradual consumption of essence and blood leading to effulgent fire can be considered as a potential mechanism. If the patient is introverted, the possibility of liver qi stagnation should be considered. If the patient comes from a region where people eat high-fat, sweet and spicy food, phlegm-heat should be considered. The patient’s characteristics, the season and the location can be the direct cause of insomnia, can have an influence on the vulnerability to insomnia and can influence the type of pattern of the patient. It can also be a source of background information to keep in mind when treating patients. For example, not using excessively dry herbs to treat menopausal women, who have a tendency toward essence and blood deficiency, or adding qi-moving herbs when treating a patient who lives in a humid region. In addition to the above considerations, the identification of the constitution of the patient can lead to a treatment extending beyond the limits of the disease. After remission of the symptoms, the patient can continue to take a constitution-based treatment that will allow him or her to have a better health globally and to prevent relapse.

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Chapter 11

Treatment According to Insomnia Subtype There is a variation to the disease-based treatment. The treatment is based or oriented according to the specificities of the disease. In the case of insomnia, these are the main complaint or symptom, the time of the episode of insomnia and the stage or type of insomnia. This approach is still different from the pattern-based approach, in which a pattern is identified according to signs and symptoms that may or may not be directly related to insomnia such as tongue and pulse features.

1. Treatment according to the complaint There are four main complaints of insomnia: difficulty falling asleep (DFA), frequent awakenings (FA), frequent dreams (FD) and early-morning awakenings (EMA). In most cases, insomnia patients present multiple symptoms at the same time and their symptoms may evolve through time. Nevertheless, some subsets of patients present one single and persistent symptom. In this case, the type of complaint may guide the reasoning of the clinician.

1.1. Difficulty falling asleep as the main complaint Insomnia with a complaint of DFA is associated with an excess pattern (2). More specifically, it is associated with: • • • • •

liver or heart fire/heat (5) liver or shaoyang stagnation (4) phlegm (2) blood stasis (2) blood deficiency (2)

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• yin deficiency (2) with hyperactive yang (1) • non-interaction between heart and kidney (1) • nutritive-protective disharmony (1). A main complaint of DFA is also associated with anxiety (2) and obsession (1).

1.2. Frequent awakening as the main complaint Insomnia with a complaint of FA is associated with a deficiency pattern (1), more specifically: • • • • • •

yin-blood deficiency (3) with liver stagnation (1) heart-gallbladder qi deficiency (1) qi and blood deficiency (1) lung yin deficiency (1) lung qi deficiency (1) lung phlegm (1).

It is also associated with depression (1).

1.3. Frequent dreams as the main complaint Insomnia with a complaint of FD is associated with the liver (2) as the spirit hun, which is associated with dreams, corresponds to the liver. More specifically, it is associated with: • • • • • •

blood deficiency (5) blood stasis (3) liver stagnation (3) liver heat (2) phlegm-heat (1) yin deficiency (1).

1.4. Early-morning awakenings as the main complaint Insomnia with a complaint of EMA is associated mostly with deficiency patterns and the kidney. More specifically, it is associated with: • yin deficiency and hyperactive yang (2) • kidney yang deficiency (2) • kidney yin deficiency (1)

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• heart blood deficiency (1) • heart-gallbladder disharmony (1) • nutritive-blood heat and liver stagnation (1). This type of insomnia is also associated with depression (3) and cerebral vascular insufficiency (1).

1.5. Quantitative analysis In order to test the association between complaints and pattern diagnosis, we conducted quantitative analyses with the dataset of herbal formulas used on a pattern basis. We first selected the formulas in which only one of the three main complaints (DFA, FA or EMA) was expressed in the description of SSs. We then calculated for each pattern the percentage of formulas for which the specific complaint was an indication to use the formula (Figures 11.1, 11.2 and 11.3). We can see from the results of the quantitative analysis that clinicians tended to associate Heart-Spleen Deficiency and Liver Fire with a unique complaint of DFA instead of FA. They also tended to associate Liver Stagnation and Blood Stasis with a unique complaint of FA instead of DFA. EMA was associated only with Yin Deficiency with Fire. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

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Figure 11.1. Percentage of formulas in which DFA was the main complaint

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Treating Insomnia with Chinese Medicine 80% 70% 60% 50% 40% 30% 20% 10% 0%

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Figure 11.3. Percentage of formulas in which EMA was the main complaint

1.6. Summary We can see from the above that there is no strict consensus on the meaning of the complaint. Generally, DFA is associated with an excess pattern and especially fire, FA is associated with a deficiency pattern and e­ specially blood deficiency, FD is associated with liver conditions  and  especially blood deficiency, and EMA is associated with deficiency and especially kidney deficiency (Figure 11.4). DFA is also associated with anxiety, while EMA is associated with depression.

2. Treatment according to the time of the symptoms Insomnia can also be diagnosed and treated according to the time of the symptoms. In Chinese culture, shichen (i.e. couple of hours) are associated with organs. The shichen related to insomnia symptoms are

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zi (from 11 p.m. to 1 a.m.) which is associated with the gallbladder, chou (1 a.m. to 3 a.m.) which is associated with the liver, and yin (3 a.m. to 5 a.m.) which is associated with the lung. In addition, the movements of the yin and yang are also related to time, with the yang going inward in the evening, the yin being extreme at midnight and the yang going outward in the morning.

2.1. Insomnia during zi hours According to the clinicians, DFA occurring during the zi hours (11 p.m. to 1 a.m.) is caused by the gallbladder-pivot being blocked (1), which should be treated with a chaihu-type formula (1) or Chai Hu Jia Long Gu Mu Li Tang (1). 2.2. Insomnia during chou hours If clinicians agree that awakenings during the chou hours (1 a.m. to 3 a.m.) are related to the liver (3), there is no consensus on the mechanism, which can be either an impossibility for the liver-wood to move upward and outward (1), a deregulation of liver function caused by emotions (1) or an imbalance with both heat and cold in the jueyin treated with Wu Mei Wan (1). 2.3. Insomnia during yin hours EMA during the yin hours (3 a.m. to 5 a.m.) is linked with kidney-­ water cold (2), the kidney yang floating prematurely as it is pushed by the ­coldness. Also, the lung-metal cannot descend as it is blocked by the coldness (1). This condition has to be treated with warm-tonifying herbs and immersing-oppressing herbs (1). Difficulty falling asleep 1. Excessive yang unable to enter the yin 2. Stagnation blocking the yang

Early-morning awakening Deficient yang floating on the top

Frequent awakenings Blood too weak to keep the yang

Figure 11.4. Visualization of the mechanism of insomnia according to the main complaint

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2.4. Summary We can see from the above that associations between time of insomnia episodes and mechanism are mainly driven by the shichen theory. However, these associations are not followed blindly as yin-hours insomnia is mainly associated with the kidney, not the lung which is the yin organ.

3. Treatment according to the stage 3.1. Early-stage and late-stage insomnia The treatment of early-stage or acute insomnia was reported far less than the treatment of late-stage or chronic insomnia. Unsurprisingly, early-stage insomnia is associated with excess (2), while late-stage insomnia is associated with deficiency (2). In the first case, zhenzhumu, hupo and duan longgu are added to an evil-removing formula, and in the second case xiyangshen, ejiao and guiban are added to a regular-tonifying formula (1). The association between early-stage insomnia and the excess pattern is supported by the fact that clinicians associated acute insomnia with liver stagnation (5), liver and heart fire (4), phlegm-heat (2), disturbed shen (2) and non-interaction between heart and kidney (1). The association between late-stage insomnia and the deficiency pattern is far less consensual. One clinician believes that the mechanism of late-stage anxiety-type insomnia is either liver stagnation with spleen deficiency or phlegm and blood stasis creating fire (1). Another clinician considers that long-term insomnia has a complex pathological mechanism (1) and has to be treated with a combination of Chinese herbal medicine and either Western medicine or psychotherapy (1).

3.2. Persistent insomnia 3.2.1. Definition of persistent insomnia As many as 77 articles focused on persistent insomnia. The definition of ‘persistent insomnia’ varied greatly from one article to another. Persistent insomnia is defined by: • • • • •

long duration (14) resistance to treatment (7) frequent relapse (3) short total sleep time (3) serious social impairment (3).

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Treatment According to Insomnia Subtype

The criterion for duration can be: • • • •

undefined (9) more than one month (1) more than three months (2) more than one year (1).

The criterion for short total sleep time can be less than two hours (2) or less than three hours (1). From the above criteria, we can see that the definition of persistent insomnia is not much different from the definition of insomnia, which refers to insomnia of three months’ duration. In some articles, ‘persistent insomnia’ is even used interchangeably with ‘insomnia’ or directly defined as ‘insomnia’. It seems that ‘persistent insomnia’ is mostly similar to the concept of chronic insomnia, which generally lasts for years, rather than a particular subtype of chronic insomnia. 3.2.2. Pathology of persistent insomnia Persistent insomnia has a complex aetiology (2), including constitutional factors, the influence of the disease and its treatment (1). Mixed patterns of deficiency/excess and cold/heat can happen when, for example, a person with a yang deficiency constitution gets congested fire because of emotions (1). As depression (4) and anxiety (4) are intertwined with persistent insomnia, a common pathway is insomnia-induced emotions (3) provoking liver stagnation (4), which in turn can provoke other mechanisms such as phlegm, blood stasis or fire. The patterns of persistent insomnia are: • • • • • •

blood stasis (12) phlegm (6) yang deficiency (3) yin deficiency with effulgent fire (2) kidney deficiency (2) qi deficiency (1).

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3.2.3. Prescriptions for persistent insomnia The formulas of the 77 CERs in which the treatment of persistent insomnia was reported were compared with the treatment of the general insomnia population. In terms of herb categories, formulas for persistent insomnia included more: • blood-activating herbs (+72%) • phlegm-transforming and anti-coughing herbs (+32%). They included less: • water-draining herbs (–29%) • blood-tonifying herbs (–12%) • spirit-calming herbs (–8%). In terms of individual herbs, formulas for persistent insomnia included more: • • • • • • • • •

yinyanghuo (+554%) honghua (+227%) jiegeng (+200%) niuxi (+170%) taoren (+170%) cishi (+145%) chishao (+121%) zhiqiao (+89%) shengdi (+28%).

They included less: • • • • • • • •

shudihuang (–72%) danpi (–58%) hehuanpi (–53%) wuweizi (–44%) fuling (–37%) zhimu (–35%) baizhu (–32%) suanzaoren (–28%)

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Treatment According to Insomnia Subtype

• baishao (–24%). From the quantitative analysis, we can see that the main difference between the treatment of insomnia in general and the treatment of persistent insomnia is a tendency to use blood-moving and phlegm-­ transforming herbs for persistent insomnia. Interestingly, with the exception of yinyanghuo, tonic herbs are not more commonly used for persistent insomnia but actually less commonly used. This contradicts the idea that long-term conditions present deficiency patterns.

4. Interpretation and discussion The analysis of the mechanism of insomnia according to the insomnia symptoms shows there is no strict consensus about the meaning of the main complaint of insomnia or of the timing of symptoms. The quantitative and qualitative analyses of the association between the main complaint and pattern are not completely consistent either. This shows that clinicians should not understand the main complaint as a strict indicator of one specific mechanism or pattern but rather as guiding the clinical thinking in a certain direction. Difficulty falling asleep is generally associated with heat and fire as the excessive yang is unable to penetrate the yin. It is also associated with liver stagnation and blood stasis as they block the penetration of the yang at dawn. Frequent awakenings are associated with blood deficiency as weak blood is unable to keep the yang (or spirit) within itself. Frequent dreams are associated with liver pathology in general, including stagnation, blood stasis, fire and blood deficiency. Early-­morning awakening is associated with kidney deficiency, either yin or yang deficiency. Either the yin is too weak to contain the yang that is rising or the yang is pushed by the coldness of the kidney. As the theory states that acute conditions are associated with excess and chronic conditions with deficiency, we might expect acute insomnia to be associated with fire, phlegm and blood stasis, and chronic insomnia to be associated with yin deficiency or qi and blood deficiency. This is not the case. The course of insomnia can be seen as a tree, in which the trunk is composed of liver qi stagnation and fire, and the branches consist of phlegm, blood stasis and kidney deficiency (Figure 11.5.). The association between persistent insomnia and kidney deficiency was not obvious in the quantitative analysis of the characteristics

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of persistent insomnia. This evolution is consistent with the ‘liver qi stagnation’ system (see Chapter 6) in which emotion-induced liver qi stagnation progresses to liver fire, phlegm-heat and blood stasis. PHLEGM BLOOD STASIS

KIDNEY DEFICIENCY

PERSISTENT INSOMNIA

ACUTE INSOMNIA

Stagnation Fire

Figure 11.5. Visualization of the mechanisms of acute and persistent insomnia

This shows that clinicians do not blindly apply the theory but take into consideration clinical observation.

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Chapter 12

Managing Comorbidities Insomnia is strongly associated with physical conditions such as chronic pain and psychological conditions such as depression and anxiety. We call these conditions ‘comorbidities’. As many clinicians have presented the treatment of insomnia in populations with a certain comorbidity, we were able to synthesize their perspective on the methods to manage insomnia present with comorbidities.

1. Common comorbidities of insomnia Insomnia is often present alongside other medical conditions (i.e. comorbidities). These comorbidities are: • • • • • • • • • • • • • • • • •

diabetes (12) depression (9) hepatic conditions (7) anxiety disorder (5) coronary heart disease (4) stroke sequels (4) gastric conditions (4) respiratory conditions (3) hypertension (3) cardiac arrhythmias (3) cervical spondylosis (2) chronic kidney failure (1) female urethral syndrome (1) Parkinson’s disease (1) prostatic hypertrophy (1) cerebral arteriosclerosis (1) brain trauma (1)

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• • • • • • •

autism (1) obsessive-compulsive disorder (1) AIDS (1) cancer (1) heart failure (1) myocarditis (1) chronic diarrhoea (1).

2. Relationship between insomnia and the comorbidity According to the clinicians, these comorbidities are either present before the start of the insomnia or at the same time, but never developed on the basis of insomnia. The causality between insomnia and the comorbidity is more complex. Insomnia and the comorbidity can be either unrelated or have the same aetiological and pathological pathway (Table 12.1). In both cases, there is no cause or consequence. The most common relationship is the comorbidity (or primary disease) being the cause of insomnia. According to the clinicians, insomnia does not cause the comorbidity but can sometimes aggravate it. Table 12.1. Common aetiological and pathological pathways of insomnia and the comorbidity Comorbidity

Common aetiological and pathological pathway

Diabetes

Phlegm-dampness and inner heat

Diabetes

Excessive diet, emotions, work–life imbalance

Diabetes

Yang deficiency

Anxiety

First liver stagnation producing fire, then phlegm, blood stasis, spleen deficiency and blood deficiency

Anxiety

Lack of yin and blood with deficient fire rising

Anxiety

Non-interaction between heart and kidney

Depression

Disharmony of heart and gallbladder

Obsessive-compulsive disorder

Stagnating fire of shaoyang

Coronary heart disease

Liver stagnation, spleen deficiency and blood stasis

Coronary heart disease

Phlegm and blood stasis

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Managing Comorbidities Cardiac condition (coronary heart disease, myocarditis, arrhythmia)

Emotions, mental strain or catching cold

Palpitations

Gallbladder or stomach impairment

Hypertension

Liver-kidney deficiency, hyperactive liver yang, phlegm-heat

Respiratory condition

Lack of rest and inappropriate treatment of cold, emotions and mental strain

We have identified five ways in which the comorbidity (or primary disease) is a basis for the development of insomnia (Figure 12.1.): 1. Insomnia is a symptom of the primary disease such as depression (2) or chronic hepatitis B (1). 2. Insomnia is caused by a symptom of the primary disease such as stomach discomfort (4), frequent urination (4), bodily pain (3), cough or dyspnoea (2), itching (2), thoracic pain (1), diarrhoea (1), abdominal bloating (1), pain in the liver area (1), palpitations (1), sleep apnoea (1), tooth pain (1). 3. The primary disease leads to emotional distress (e.g. excessive despair, anxiety and rumination), which then causes insomnia. This emotional distress is due to an incorrect view of the disease, worry about relapse or aggravation, financial burden, social stigma and pressure, adverse reactions from treatment, the stress of constantly monitoring the disease (e.g. glycaemia for diabetics). 4. The treatment of the primary disease causes insomnia. For instance, in the case of cancer, chemotherapy can harm the qi and blood, which leads to insomnia (1). 5. The evolution of the pathology of the primary disease leads to insomnia (Table 12.2). Both the original mechanism and the evolution of the disease are extremely varied. For example, yin deficiency can lead to fire; qi stagnation and heat can provoke phlegm, fire and blood stasis; fire can consume yin and blood; the source of qi and blood can be impaired.

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Insomnia

Cormorbidity

Emotions

Symptoms Cormorbidity

Insomnia

Treatment

Paern

Cormorbidity

Insomnia

Figure 12.1. Visualization of the causal relationship between insomnia and comorbidities Table 12.2. Aetiology and mechanism of the primary disease and evolution leading to insomnia Primary disease

Aetiology and mechanism

Evolution

Diabetes (9)

Yin deficiency with drynessheat (4); excessive diet creating phlegm-dampness overwhelming the spleen and excessive emotions impairing the liver (1); qi and yin deficiency (1)

Phlegm and phlegm-heat (6); blood stasis (4); liver stagnation producing fire (3); fire disturbing the heart (2); liver blood deficiency (1); qi and blood deficiency (1)

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Managing Comorbidities Stroke (3)

Heat, phlegm, blood stasis, deficiency and inner wind (1), phlegm-heat (1)

Blood stasis (1); phlegm-heat (1); yinyang dysregulation (1)

Hepatic condition (3)

Dampness-heat and liver stagnation (1)

Liver qi stagnation (2); dampness-heat in the liver meridian (2); liver blood deficiency (2); spleen unable to produce blood (1); yin deficiency with effulgent fire (1); liver stagnation producing fire (1) and phlegm-fire (1)

Digestive disorder (2)

Excessive emotions impairing the liver, which harms the spleen (1)

Stomach disharmony (1); qi and blood deficiency (1); phlegm-dampness (1)

Respiratory conditions (2)

Stagnation, heat, phlegm, dryness or coldness in the lung (1)

The lung qi cannot produce the blood (2)

Chronic renal failure

The kidney is not able to transform the turbid, which blocks the three burners

The qi and blood are deficient or do not circulate well

Parkinson’s disease

Liver-kidney yin deficiency

Excessive heart fire

Cervical spondylosis

External affliction of wind, cold and dampness, trauma or chronic damage leads to contraction of tendons and joint displacement

The qi and blood cannot irrigate the brain

Cerebral arteriosclerosis, cervical spondylosis, brain trauma, hypertension

Blood stasis

Depression

Liver stagnation due to irregular emotions

Stagnating fire harming the yin

Autism

Heart, liver, spleen and kidney function impairment, phlegm and blood stasis

Yinyang imbalance and abnormal circulation of nutritive and protective

Insomnia can also aggravate the comorbidity (i.e. stroke, coronary heart disease) by: • disrupting the endocrine system (1) • creating anxiety (2)

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• exciting the sympathetic system (1) • increasing insulin antagonist hormones (1). As one clinician put it, ‘it is hard to differentiate which one is the cause and which one is the consequence’.

3. Treatment of comorbid insomnia Regarding treatment, it is difficult to extrapolate the different possible strategies when treating insomnia with comorbidities. This difficulty comes from the fact that pattern differentiation based on signs and symptoms is the main diagnostic approach in Chinese medicine. The SSs can be due to either insomnia or the comorbidity, and it is difficult to assess if the treatment targets insomnia, the comorbidity or both. Despite this difficulty, we were able to identify five strategies.

3.1. Focus on the comorbidity with a patternbased or disease-based treatment Example 1 Insomnia induced by cervical spondylosis is treated with gegen, chuan­ xiong, jianghuang and quanxie, which mainly target the cervical spondylosis by releasing the tendons and unblocking the vessels. Example 2 Insomnia provoked by respiratory conditions is treated according to the pattern with Sang Bai Pi Tang, Er Chen Tang with San Zi Yang Qin Tang, or Bai He Gu Jin Tang. Although the treatment is focused on the comorbidity, spirit-calming herbs can be added to the treatment (as a symptomatic or disease-based treatment). The rationale behind this strategy might be that insomnia is directly caused by the comorbidity or its symptoms, and treating the comorbidity alone is enough to get rid of the insomnia. Or it might be that insomnia is not considered severe enough compared with the comorbidity. The comorbidities for which this approach is used are: • cervical spondylosis (1) • respiratory conditions (2) • chronic hepatitis (1)

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• cardiac failure (1) • diabetes (1).

3.2. Focus on insomnia with a pattern basis In this case, the treatment is not different from the usual pattern-based treatment of insomnia. Example Insomnia in heroin addiction rehabilitation is treated according to the pattern with Gui Pi Tang, Huang Lian E Jiao Tang, Jiao Tai Wan, An Shen Ding Zhi Wan, Qing Re Di Tan Tang and Bao He Wan, which are all commonly used for insomnia. The rationale behind this approach might be that the comorbidity and insomnia are not directly related, and therefore there is no need to treat the comorbidity in order to improve insomnia. The comorbidities for which this approach is used are: • • • •

chronic renal failure (1) heroin addiction rehabilitation (1) diabetes (1) AIDS (1).

3.3. Treat both conditions at the same time with one formula In this approach, the common pathological mechanisms of the two conditions are targeted. Example 1 The common mechanism of stroke and insomnia, phlegm, is targeted by the phlegm-transforming formula Wen Dan Tang. Example 2 The common mechanism of palpitations and insomnia, gallbladder and stomach impairment, is targeted by a set of formulas including Huang Lian Wen Dan Tang, An Shen Ding Zhi Wan with Suan Zao Ren Tang, and Hao Qin Qing Dan Tang with Hua Gan Jian. A 64-year-old male consulted for difficulty falling asleep with dizziness and fatigue following a dispute with a family member. The patient was diagnosed with major depression and had been taking fluoxetine for a

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long time. One month previously, the symptoms worsened, the patient had trouble falling asleep, woke up easily and had trouble getting back to sleep; other symptoms were agitation, suicidal thoughts, weakness and coldness in the lower limbs, lack of appetite, weight loss and dizziness. The stools were normal. He was obese with a phlegm constitution. The tongue was dark red with a yellow and greasy coating. The pulse was wiry and slippery. This is a pattern of shaoyang pivot blocked with phlegm-fire ascending. He was treated with Huang Lian Wen Dan Tang combined with Zhi Zi Chi Tang: huanglian 6g, fa banxia 9g, chenpi 12g, fuling 15g, gancao 9g, zhishi 10g, baihe 18g, yujin 12g, changpu 10g, sheng longchi 30g, zibeichi 30g, dannanxing 9g, chao zhizi 10g, dandouchi 10g, lianzixin 9g, hupo powder 4g, zhenzhu powder 0.6g (add before taking the decoction). After 35 bags, the situation was improved; he could sleep 6–7 hours per night and his mood was better. The rationale behind this approach might be that there is an overlap between the pathological mechanism of the two conditions, or that insomnia is the result of the evolution of the comorbidity. The treatment targets directly that shared mechanism. The comorbidities for which this approach is used are: • • • • • • • • • • • • • • • •

diabetes (9) depression (4) stroke (3) palpitations (2) chronic hepatic disease (2) chronic hepatitis B (2) autism (1) anxiety (1) Parkinson’s disease (1) obsessive-compulsive disorder (1) cardiac arrhythmia (1) pruritus (1) vertigo (1) mental disorders (1) chronic gastritis (1) digestive conditions (1).

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3.4. Treat both conditions with a mixed pattern-disease approach In this strategy, the main formula targets either insomnia or the comorbidity and the formula is modified according to the pattern of insomnia or the comorbidity. Example 1 In the case of insomnia with comorbid coronary heart disease, danshen, chuanxiong, gualou and xiebai are used to target the coronary heart disease and the formula is modified according to the pattern of insomnia. Example 2 In the case of insomnia comorbid with a gastric condition, a basic formula composed of liver-inhibiting and liver-draining herbs is used for insomnia and modified according to the pattern of the gastric condition. The rationale behind this approach might be that one of the conditions presents patterns that are different from the core mechanism of the other condition. The comorbidities for which this approach is used are: • coronary heart disease (1) • gastric disease (1) • chronic hepatitis B (1).

3.5. Treat both conditions with a combination of two disease-based formulas In this situation, a formula targeting insomnia and another formula targeting the comorbidity are combined. Example Suan Zao Ren Tang is combined with Dan Shen Yin in order to treat insomnia comorbid with coronary heart disease, the first formula treating the first condition and the second formula treating the second condition. The rationale behind this approach might be that the two conditions have different core mechanisms. The comorbidities for which this approach is used are: • coronary heart disease (1) • hepatic diseases (1)

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• • • • •

chronic diarrhoea (1) female urethra syndrome (1) respiratory conditions (1) heart diseases (1) liver cancer (1).

4. Interpretation and discussion Among the comorbidities that were described by the clinicians, we can find conditions that are known to be associated with insomnia such as mental disorders and neurological diseases. From a biomedical perspective, there is no direct association between insomnia and cardiovascular diseases, diabetes, liver conditions and digestive conditions. However, in Chinese medicine these conditions can be related. Cardiovascular diseases and insomnia both involved the ‘heart’ and therefore share common pathological pathways. In diabetes and liver conditions, the pattern can evolve and lead to insomnia (this may involve complex endocrine, neurological and immunologic mechanisms). Finally, digestive conditions are associated with insomnia from the Chinese medicine perspective of ‘when the stomach is not in harmony, the sleep is agitated’. Interactions between insomnia and the comorbidity are complex and involve the two conceptual levels of ‘pattern’ and ‘disease’. Insomnia and the comorbidity can be unrelated. In this case, the clinician has the choice to treat insomnia without targeting the comorbidity, focus on the main condition and add herbs to target the secondary condition, or use a mix of two formulas that target each condition. If the two conditions share a common pattern, the treatment has to focus on the pattern. This is the most common situation. Finally, if insomnia is caused by the comorbidity (or primary condition), then the treatment should target the comorbidity, with the use of shen-calming herbs as a disease-based treatment.

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Chapter 13

Cooking, Intake Methods and Treatment Duration 1. Cooking methods for insomnia patients There are only a few recommendations on the method of cooking of the herbs. These are cooking spirit-calming herbs for a longer time (1) and asking the family to cook the herbs in order to avoid exhausting the patient (1).

2. Timing of the intake In terms of time of intake, it is usually recommended to take the herbs once in the afternoon and once in the evening (8) instead of the traditional morning-and-evening intake. The reasons for this are: • to attain an optimum blood concentration (3) • to adhere to the natural rise of the yin during the second half of the day (2) • to increase the strength of the treatment without having to increase the dose (1) • to avoid daytime sleepiness (1). The precise time can be 2 p.m. (1) or 4 p.m. (1) for the afternoon intake and 8 p.m. (1), 9 p.m. (1), 1–1.5 hours before bedtime (1) or two hours before bedtime (1) for the evening. It is also possible to take the first cooking (which is more concentrated) two hours before bedtime and the second cooking (which is less concentrated) in the morning (3). Alternatives include:

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• taking the herbs three times a day, either before meals (1) or twice during the daytime and once at night (1) • taking all the herbs at once (2), especially where the case is severe (1).

3. How to deal with weak patients If the patient is weak (1) or if he/she has stomach conditions (1), he/she should take low doses of the decoction frequently. If the patient cannot handle decoctions, herbal infusions can be used instead (1).

4. Before or after meals? It is preferable to take the decoction before the meal in the case of: • deficiency patterns such as Heart-Spleen Deficiency, Liver Blood Deficiency or Liver-Kidney Deficiency (1) • Phlegm-Dampness or Phlegm-Heat as the herbs will help to regulate the stomach during the meal (1). It is preferable to take the decoction after the meal in the case of: • congested fire in the upper part of the body, as it would provoke vomiting if taken before the meal (1) • blood stasis, as qi-moving herbs and blood-activating herbs can damage the stomach (1).

5. Using different formulas in the same day Taking different formulas during the day and at night is another alternative (4). The night-time formula can either be the same formula with the addition of heavy-sedative herbs (1) or a completely different formula (3). In this case, the daytime formula mainly regulates the movements of the qi (1), regulates the yinyang (1) or regulates the liver (1), and the nighttime formula appeases the spirit (2) or drains the liver and appeases the spirit (1).

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6. Duration of the treatment The duration of the treatment is rarely mentioned by clinicians – the treatment should last for 1–2 weeks (1), two weeks (1) or 2–4 months (1).

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Chapter 14

Shen-Calming Herbs Shen-calming herbs are those which, by definition, have a calming or inhibiting effect on the spirit or shen. Pharmacological studies found that many of these herbs have sedative and hypnotic effects. They are used on a symptomatic basis to treat palpitations and insomnia (Figure 14.1.). There are two categories of shen-calming herbs – the heavy-sedative herbs and the heart-nurturing herbs. Additionally, many herbs which do not belong to the category of shen-calming herbs such as fuling have shen-calming effects.

1. Overview As the disturbance of the spirit is one of the main features of insomnia, the use of spirit-calming herbs for the treatment of insomnia is not surprising. In most cases, clinicians recommended using spirit-­calming herbs on the basis of pattern differentiation (25). Many clinicians recommended avoiding treatment with mainly spirit-calming herbs (10) or even to limit their use (3), especially the use of heavy-sedative herbs (3). They explained that the efficacy of this approach is low (2), especially for moderate and severe types of insomnia (1). Only one clinician recommended using a spirit-calming formula as the main formula (1).

2. Categories In addition to the two main categories of spirit-calming herbs (heart-­ nurturing and heavy-sedative), two other categories of spirit-calming herbs have been proposed by the clinicians – namely, stagnation-eliminating and orifice-opening (Table 14.1). The stagnation-eliminating spirit-calming herbs are indicated when there is both liver qi stagnation

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Shen-Calming Herbs

and a disturbed spirit, while the orifice-opening spirit-calming herbs are indicated when there is loss of memory. Other herbs are known for their spirit-calming properties but are not classified in any category, and therefore we labelled them ‘other typical spirit-calming’ herbs. Finally, some herbs that are not considered to have spirit-calming properties were identified by the clinicians as spirit-­ calming. This is the case for banxia (5), huanglian (3), chaihu (1), kushen (1), baishao (1) and chantui (1). These herbs were identified as spirit-calming on the basis of either individual experience or pharmacological studies. Table 14.1. Different categories of shen-calming herbs Heartnurturing

Heavysedative

Stagnationeliminating

Orificeopening

Other typical

Atypical

suanzaoren baiziren yejiaoteng hehuanpi hehuanha longyanrou lianzirou lingzhi

longgu muli zhenzhumu cishi hupo zhusha longchi zibeichi shengtieluo

huashengye hehuanhua hehuanpi gansong suxinhua

changpu yuanzhi

fuling fushen xiecao wuweizi

banxia huanglian chaihu kushen baishao chantui

suanzaoren zhenzhumu

muli

fuling yejiaoteng zhusha

lingzhi

wuweizi

changpu

baiziren

hehuanpi longchi

zibeichi

fushen

longyanrou

yuanzhi hehuanhua

hupo

longgu

gansong

cishi

Figure 14.1. Shen-calming herbs used in the pattern-differentiation approach The size of the words is proportional to the number of citations.

The type of shen-calming herb used has to be chosen according to the following.

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A. The duration and severity of the disease Heavy-sedative herbs for short-term (2) and severe conditions (1), and heart-nurturing for long-term (2) and mild conditions (1). B. The pattern of the patient (3) Use qi-moving, blood-moving or phlegm-transforming shen-calming herbs if there is qi stagnation, blood stasis or phlegm (1); heavy-­sedative for ‘moving’ patterns and heart-nurturing for ‘quiet’ patterns (1); or heavy-sedative for excess patterns and heart-nurturing for deficiency patterns (1). There is a debate on this last point as some clinicians recommend using heavy-sedative herbs (5) or heart-nurturing herbs (5) on a ­disease-differentiation basis regardless of the pattern. A possible explanation is that both types of shen-calming herbs can be used for any type of insomnia but they are more appropriate for some types of insomnia. Indeed, one clinician mentioned that suanzaoren is more appropriate for Yin Deficiency but can be used for other patterns when used in combination with other herbs.

3. Use of shen-calming herbs according to the pattern 3.1. Use of shen-calming herbs according to excess or deficiency patterns In order to test the hypothesis that ‘heavy-sedative herbs are recommended mostly (or only) for excess patterns and heart-nurturing herbs are recommended mostly (or only) for deficiency patterns’, we analysed the relationship between the use of these herbs and the degree of deficiency/excess of the pattern. The degree of deficiency/excess of the pattern was defined as the percentage of tonic herbs (such as renshen, danggui, etc.) in the formula. The percentage of heart-nurturing, heavy-sedative, typical (including heart-nurturing, heavy-sedative, stagnation-eliminating, orifice-opening and other typical shen-calming herbs) and all shen-calming (including both typical and atypical spirit-calming herbs) herbs according to the percentage of tonic herbs (which reflects the excessive deficient nature of the pattern) is shown in Figure 14.2.

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Shen-Calming Herbs 0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0

0–9%

10–19%

20–29% 30–39% 40–49% 50–59% 60–69% 70–79% Heart

Heavy

Typical

All

Figure 14.2. Categories of shen-calming herbs used according to the percentage of tonic herbs The y-axis represents the proportion of shen-calming herbs in the formula while the x-axis represents the percentage of tonic herbs in the formula.

The percentage of tonic herbs is positively correlated (r=0.102, P=0.023) with the percentage of heart-nurturing herbs, and negatively correlated (r=–0.243, P