Insomnia means insufficient duration of sleep or sleep of poor quality. In mild cases, it may be difficulty in falling asleep or frequent waking from sleep. In severe cases, it may be inability to fall asleep all night.
In general, insomnia may be caused by exogenous illness or by internal injury. Exogenously induced insomnia most commonly occurs during the course of the various illnesses of Heat. Endogenously induced insomnia is primarily due to deficiency. In this topic the emphasis is on endogenously induced insomnia.
Etiology and Pathology
A weak constitution or a chronic illness can cause insomnia. The constitution may be inherently weak or be weakened by illness. Most illnesses that weaken the constitution do so through injury to the heart and the spleen, through impairment of the generation of Qi and blood, through failure of nourishment of the heart, or through blood depletion. Exhaustion of kidney-Yin, flaring of Heart-Fire and disturbance of the mind can also cause insomnia.
The passions are among the common causes. Excessive brooding injures the heart and the spleen and may result in failure of heart nourishment. Sudden and violent fright may lead to deficiency of heart and gallbladder Qi and conduce to the production of Phlegm and Heat. Pent-up rage impairs the liver, conducing to stagnation of liver-Qi and its transformation into Liver-Fire; and Liver-Fire in turn can disturb the mind and induce insomnia.
An immoderate diet, with excessive consumption of spices, fats and sweets over a long period of time, can impair the spleen and the stomach. These organs may fail in their transportation and transformation functions, permitting Dampness to accumulate. If Dampness is permitted to gel, it may produce Phlegm and give rise to Heat. Phlegm and Heat together can cause obstruction in the middle-jiao and upward disturbance of the mind, leading to insomnia.
Excessive resting with too little activity can lead to deficiency of spleen-Qi, so that the spleen fails in its transporting and transforming functions. The essence of foods and drinks become unavailable for the generation of Qi and blood, so that nourishment of the heart fails. This also leads to insomnia.
Key Points of Analysis
Types of Insomnia. The clinical features of insomnia are related to its cause, its severity and its duration. In general, if the patient is able to fall asleep but readily awakens and is then unable to fall asleep again, it is mostly due to insufficiency of both the heart and the spleen. If difficulty falling asleep is associated with restlessness, palpitation of the heart, aphthous sores in the mouth and mouth dryness in the night, it is mostly due to flaming Fire in Yin deficiency. If the patient falls asleep readily but wakes up with fright and is generally fearful and irascible, with frequent sighing, it is mostly due to insufficiency of the heart and the gallbladder, or to blood insufficiency and liver hyperactivity.
Visceral Organ Affected. Because different visceral organ dysfunction can produce insomnia, its associated symptoms also differ. For example, if insomnia is accompanied by anorexia, loss of taste, postprandial epigastric and abdominal distention, loose feces, sallow complexion, foul eructation or acid regurgitation, it is mainly due to illness of the spleen and the stomach. If insomnia is associated with frequent dreams, dizziness, headache and forgetfulness, it is mainly due to illness of the heart.
Deficiency or Strength. Insomnia may be of the deficiency or strength type. The deficiency type is mainly due to Qi and blood deficiency, so that the heart loses its function of nourishment, or due to Yin deficiency with strong Fire. This type is commonly associated with restlessness. The strength type is mainly due to Phlegm-Heat causing upward disturbance, and typically shows agitation, irascibility, a bitter taste in the mouth and a dry throat, constipation and dark urine.
The treatment of insomnia focuses on Qi, blood, Yin and Yang, and on the visceral organs affected. The general principle is: “Replenish what is deficient, purge what is excessive, and treat deficiency and strength.” The goal is to regulate Qi and blood, balance Yin and Yang, and restore to the normal functions of the visceral organs. At the same time, it is important on the basis of the clinical circumstances to select an appropriate method to calm the mind.
Hyperactivity of Heart-Fire
Main Symptoms. In addition to insomnia: dysphoria, restlessness; a dry mouth and tongue; sores in the mouth and on the tongue; and scanty dark urine. The tongue tip is red, with a thin yellow coating, and the pulse is rapid.
Therapeutic Principle. Purge Heart-Fire and calm the heart and the mind.
Treatment. Zhusha An Shen Wan (Cinnabar Tranquilizer Pill). It has the following composition: huanglian (Coptis) 5 g, huangqin (Scutellaria) 10 g, zhizi (Gardenia jasminoides) 10 g, lianqiao (Forsythia) 10 g, gandihuang (Rehmannia) 12 g, dang-gui (Angelica) 10 g, cinnabar treated fushen (Poria) 10 g and gancao (Glycyrrhiza) 6g.
If irritability, dyspnea and nausea are prominent, add dandouchi (Glycine max) and zhuru (Phyllostachys nigra).
If there is constipation and the urine is dark, in addition to insomnia, add raw dahuang (Rheum palmatum) and danzhuye (Lophatherum gracile).
Deficiency of Both the Heart and Spleen
Main Symptoms. Difficulty falling asleep, or frequent dreams and wakening easily followed by difficulty falling asleep again. Sometimes accompanied by palpitation of the heart, panic, lassitude and weakness; tastelessness or postprandial abdominal distention; and a sallow complexion. The tongue is pale, with a white coating, and the pulse is even but feeble. Often there has been recent major surgery, blood loss or anemia. Females often have had uterine bleeding or excessive menses.
Therapeutic Principle. Strengthen both the heart and the spleen, nourish blood and sedate the mind.
Treatment. Gui Pi Tang, with modifications as required.
If there has been obvious blood insufficiency, add shudihuang (Rehmannia), baishaoyao (Paeonia) and ejiao (Equus asinus).
For severe insomnia add wuweizi (Schisandra), hehuanpi (Albizia julibrissin) and yejiaoteng (Polygonum multiflorum).
If dreaming is excessive and there is a tendency to easy panic, add longchi (fossil teeth) and zhenzhumu (Pteria magaritifera).
Strong Fire due to Yin Deficiency
Main Symptoms. Difficulty falling asleep with restlessness; hotness in the palms and soles; night sweat; dry mouth and throat with thirst, or lingual and buccal aphthous sores. The tongue is red, or only the tip of the tongue, and the coating is scant. The pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin to suppress Fire, clear Heat in the heart and sedate the mind.
Treatment. Modified Huanglian Ejiao Tang (Coptis-Donkey-Gelatin Decoction), which has the following composition: huanglian (Copti:s) 6 g, huangqin (Scutellaria) 10 g, shengdihuang (Rehmannia) 12 g, baishaoyao (Paeonia) 12 g, ejiao (Equus) 12 g, and jizihuang (egg yolk) one piece. Alternately, Zhusha An Sheng Wan or Tian Wang Bu Xin Dan may be used.
If Liver-Fire is particularly strong, consider adding longdancao (Gentiana) and zhizi (Gardenia).
If there is frequent spermatorrhea as well, add zhimu (Anemarrhena) and huang-bai (Phellodendron).
If there is disharmony between the heart and the kidney, add rougui (Cinnamomum) to conduct Fire back to its origin, the Life-Gate.
Stagnated Liver Qi Turning into Fire
Main Symptoms. Difficulty in falling asleep; when asleep, frequent dreams, sometimes nightmares; restlessness, irascibility; chest and subcostal fullness; dizziness, head distention; conjunctival congestion; tinnitus; constipation; dark urine; a red tongue with yellow coating, and a taut and rapid pulse.
Therapeutic Principle. Clear the liver to reduce Fire, calm the heart and sedate the mind.
Treatment. Modified Longdan Xie Gan Tang (Liver-Clearing Gentiana Decoction), with the following composition: longdancao (Gentiana) 6 g, huangqin (Scutellaria) 10 g, zhizi (Gardenia) 10 g, cheqianzi (Plantago) 10 g, zexie (Alisma) 10 g, chaihu (Bupleurum) 6g, shengdihuang (Rehmannia) 10 g, danggui (Angelica) 10 g, cinnabar-treated fushen (Poria) 10 g, raw longgu (fossil bone) 15 g, raw muli (Ostrea) 15 g, and gancao (Glycyrrhiza) 6g.
For severe chest and subcostal fullness, with frequent sighing, add yujin (Curcuma) and xiangfu (Cyperus) to soothe the liver and relieve depression.
For severe dizziness and distending headache, irascibility and constipation, add luhui (Aloe vera) and raw dahuang (Rheum).
Phlegm-Heat Disturbing the Interior
Main Symptoms. Insomnia, agitation; a bitter taste; dizziness with a heavy head; chest tightness; nausea with eructation; and much sputum. The tongue is reddish, with a yellow and greasy coating. The pulse is slippery and rapid.
Therapeutic Principle. Dissipate Phlegm, purge Heat, nourish the heart and sedate the mind.
Treatment. Qing Huo Di Tan Tang (Fire-Purging Phlegm-Cleansing Decoction). It has the following composition: bile-treated nanxing (Arisaema consanguineum, erubescens) 10g, beimu (Fritillaria) 10g, ginger-treated zhuru (Phyllostachys nigra) 10 g, baiziren (Biota) 10 g, fushen (Poria) 10 g, danshen (Salvia) 10 g, baijiang-can (Bombyx) 10 g, juhua (Chrysanthemum) 10g, chenpi (Citrus tangerina) 10 g, yuanzhi (Polygala) 6 g and shenqu (medicated leaven) 10 g.
When the condition has improved, it is permissible to continue this herbal formula in pill form in order to consolidate the therapeutic effect.
For most mild cases, it is appropriate to use Wen Dan Tang (Gallbladder-Warming Decoction) instead.
Disturbance of Stomach-Qi
Main Symptoms. Insomnia accompanied by indigestion, with such symptoms as epigastric distention or pain, nausea or vomiting; foul eructation; acid regurgitation; and malodorous feces or constipation. The tongue coating is yellow and either greasy or dry. The pulse is taut and slippery or rapid and slippery.
Therapeutic Principle. Settle the stomach and relieve indigestion.
Treatment. Mild cases are commonly treated with Bao He Wan or Yue Ju Wan augmented with shanzha (Crataegus), maiya (Hordeum) and laifuzi (Raphanus). Severe cases are more appropriately treated with Tiao Wei Cheng Qi Tang. This formula, however, should be stopped as soon as the movement of Qi becomes smooth.
If indigestion is relieved but stomach-Qi is not yet smooth functioning and insomnia is still present, use Banxia Shumi Tang (Pinellia-Sorghum Decoction) to regulate stomach-Qi.
Acupuncture is quite effective in treating insomnia. The most commonly selected acupoints include Shenmen (HT-7), Sanyinjiao (SP-6), Xinshu (BL-15), Shenshu (BL-23), Zhaohai (KI-6) and Yongquan (KI-1). Depending on the clinical circumstances, some acupoints may be omitted and others included.
For insufficiency of heart-blood select Zhongwan (CV-12), Qihai (CV-6), Sanyinjiao (SP-6), Baihui (GV-20) and Tongli (HT-5). Apply the reinforcing method and add moxibustion.
For blazing Fire due to Yin deficiency select Tongli (HT-5), Neiguan (PC-6), Shaofu (HT-8) and Sanyinjiao (SP-6). Apply the reducing method and retain the needles for 20 min.
For disharmony of the stomach, select Zhongwan (CV 12), Neiguan (PC 6), Gongsun (Sp 4), Fenglong (ST 40), Neiting (ST 44) and Shenmen (HT 7), insert with mild reinforcing and reducing method. For hyperactivity of the liver and the gallbladder fire, select Yangbai (GB 14), Ganshu (BL 18), Danshu (BL 19) and Taichong (LR 3), insert with reducing method and reserve the needles for 20 min. Acupuncture treatment should be applied 2 h before sleep.
Case Study 1
The patient was a 38-year old female blue-collar worker. She presented with insomnia, palpitation of the heart, forgetfulness, dizziness, lassitude, anorexia and scant menses. Her tongue was pale, with a thin white coating, and her pulse was depletive and soft.
Diagnosis. Insomnia due to insufficiency of the heart and the spleen, with deficiency of both Qi and blood, so that nourishment of the heart-mind failed.
Therapeutic Principle. Augment Qi, generate blood and sedate the mind.
Treatment and Course. The prescription used was based on Gui Pi Tang. It had the following composition: taizishen (Pseudostellaria heterophylla) 9 g, singed baizhu (Atractylodes) 9 g, danggui (Angelica) 9 g, fuling (Poria) 9 g, fried huangqi (Astragalus) 9g, longyanrou (Euphoria longan) 9g, muxiang (Aucklandia) 2.4 g, fried yuangzhi (Polygala) 4.5 g, stir-fried zaoren (Ziziphus) 15 g, baked ganjiang (Zingiber) 1.5 g, dazao (Ziziphus) five pieces, and fried gancao (Glycyrrhiza) 3 g.
Following three daily treatments, the patient was able to sleep better and the palpitation also abated. This prescription was continued for a while to consolidate the effect.
Case Study 2
The patient was a 36-year old male. He had insomnia for several years, sometimes unable to sleep at all through the entire night. He frequently had recurrent aphthous sores in the mouth and on the tongue. In addition, he had dizziness and headaches. At the time of presentation he had much thirst with desire to drink large amounts. His tongue was red, with scant coating. His pulse was threadlike and rapid.
Diagnosis. Insomnia due to disharmony of the heart and the kidney, with deficiency-Fire flaming upward.
Therapeutic Principle. Nourish Yin, suppress Yang and harmonize the heart and the kidney.
Treatment and Course. The following composition was prescribed: guiban (Chinemys) 24 g, muli (Ostrea) 18 g, gouqizi (Lycium) 12 g, shengdihuang (Rehmannia) 12 g, zaoren (Ziziphus) 12 g, huanglian (Coptis) 1.8 g, chuanxiong (Ligusticum) 1.8 g, tianma (Gastrodia) 4.5 g and rougui (Cinnamomum) 0.6 g.
After five daily treatments, the patient was able to fall asleep more easily and no longer stayed up all night.