Broadening Strategies in the Treatment of Insomnia
By Jake Paul Fratkin, OMD, LAc
Successful treatment of insomnia can be an elusive goal, especially in patients who have a chronic condition (more then five years) or in later life (after age 50). The difficult cases tend to be those based in deficiency, rather than excess. Cases of excess respond quite quickly with herbal intervention.
Modern TCM literature describes four types of insomnia: "Difficult to sleep" indicates inability to fall asleep; "early awake" indicates those who fall asleep but then wake later; "light sleep" describes those unable to obtain a deep sleep or who are disturbed by dreams or nightmares; and "awake all night," the most serious type, indicates patients who lie awake throughout the night.1,2
There are temporary causes of insomnia that will go away once the causes are removed: bright lights, noise, episodes of grief or shock, etc. In cases where sleeplessness is secondary to illness, such as cough, fever or pain, those conditions need to be treated, rather then insomnia.
The number of hours of required sleep is relative. Some people do fine with a relatively short amount of sleep. One should question the patient whether they are bothered by their sleep cycles, especially if they are tired or moody because of poor sleep. Of course, patients not bothered by their sleep won't mention it, but it is always important to ask, especially on the first visit, how their sleep is, whether they feel it is adequate, and details regarding when they sleep, when they awake, and whether they sleep through the night. Waking once, or even twice, for urination should be considered normal, as long as they can fall back asleep easily. That being said, I recommend that patients who are stressed in general should try to get eight and a half hours of sleep each night. If they can't delay the time they wake up due to obligations, they should try to get to bed earlier.
In modern TCM literature, there is agreement of five common differentiations, two being excess patterns, and three being deficiency patterns.2 Excess patterns tend to be more recent in onset, while deficiency (usually of qi and blood, but also yin) accounts for most of the chronic and prolonged cases. There also exists mixed deficiency and excess types, which are primarily deficiency with excess arising later. Excess can be due to emotional factors or overwork. Deficiency may be due to weak constitution, prolonged illness, worry and anxiety, which can aggravate or cause deficiencies of qi, blood or yin.
Stagnation of Liver Qi Transforming into Liver Fire. In this excess pattern, prolonged emotions such as anger, suppressed depression, shock or worry lead to stagnation of liver qi. As this transforms in to liver fire, it flares up to disturb the mind. This is the cause of the "difficult to fall asleep" pattern, and is different from deficiency fire (described below), which tends to cause "light sleep." There is an inability to fall asleep until later, and may be followed by vivid or manic dreams.
In most cases, we would expect to see red along the edges of the tongue in the liver-gallbladder region. In some cases, the whole tongue is red. Other signs that would confirm this pattern are red or burning eyes, tendency towards headache, quick to anger or irritability. The pulse will be taut in the superficial aspect and rapid.
The recommended formula is a modified Long Dan Xie Gan Tang. If you only use prepared herbal products, you can use the traditional formula, but I would recommend combining with another product that settles rising yang and calms shen. If you can customize the formula, numerous modifications are recommended. Important additions include fu shen (Radix poria), long gu (Os draconis), and mu li (Concha ostrea) to settle the heart and calm shen. To reinforce soothing and dredging of the liver, add yu jin (Rhizome curcuma) and xiang fu (Rhizoma cyperi rotundi).
Disturbance of Phlegm-Heat. This excess pattern is due to over-eating or over-drinking, and is seen in patients whose dietary habits become obvious with questioning or observation. The tongue is usually coated, and the pulse is soft or slippery. These cases usually have a pre-existing deficiency of spleen qi. With over-eating, phlegm accumulates, which turn to heat, disturbing the mind. The recommended formula is Wen Dan Tang with the addition of huang lian (Rhizoma coptidis) and zhi zi (Fructus gardenia jasminoides) to clear heat in the heart. Personally, I don't see this pattern very often. Often, the patent medicine Bao He Wan or Curing Pills is adequate.
Hyperactivity of Fire Due to Yin Deficiency. This deficiency pattern is quite common, and accounts for the "early awake" and "light sleep" types. The tongue might be red or appear normal. Occasionally, only the tip appears red. The pulse tends to be thin and rapid. Patients with this pattern are nervous, have anxiety and worry issues, and wake to problem-solve. Also, pre-existing kidney yin deficiency fails to moisten and cool the heart, and heart fire develops. Here, the heart-kidney relationship fails; cold remains below and fire accumulates above. This may manifest as cold feet with flushed cheeks. In males, this pattern may also contribute to nocturnal emission. The therapeutic principle is to clear heat, nourish yin and calm shen.
The recommended formula is not available as an herbal product. It is Huang Lian E Jiao Tang, which consists of huang lian (Rhizoma coptidis), e jiao (Asini corii gelatinum), huang qin (Radix scutellariae), bai shao (Radix paeonia lactiflora) and ji zi huang (egg yolk). A secondary recommendation available as an herbal product is Tian Wang Bu Xin Dan. In this case, I would recommend combining the Tian Wang formula with the single herb coptis huang lian, which is available in pill form.
Deficiency of Both Heart and Spleen. In cases of chronic insomnia, the cause may be blood deficiency due to spleen deficiency. This results in the "light sleep" pattern and is commonly seen in the aged, or those recuperating from surgery or a long illness. Accompanying symptoms may include palpitations, anxiety and low spirits. The tongue is pale and the pulse is thin and weak. The treatment principle is to nourish the heart, but also to invigorate the spleen to generate qi and blood. The prescription Gui Pi Tang is used, but it is best when modified with the additions of shu di huang (Radix rehmanniae glutinosae preparata), bai shao and e jiao.
Deficiency of Heart and Gallbladder. This pattern is seen in people who have been frightened, worry excessively or are pessimistic. Fright and worry deplete gallbladder qi, which affects the heart. These patients wake and then stay awake. They show signs of qi deficiency, including fatigue and low spirits. The pulse is thin and weak, although the tongue appears normal. The recommended treatment is the formula An Shen Ding Zhi Tang. Currently I know of only one company making the formula as a patent medicine. In cases with severe deficiency of qi and blood, the formula is combined with Gui Zhi Gan Cao Tang or Suan Zao Ren Tang.
Modern Chinese literature also suggests the practitioner advise the patient on self-monitoring for sources of irritation or worry. It is recommended against drinking alcohol or tea before bedtime, and to avoid radio or television before bedtime. One should sleep in a quiet environment. Thirty to 60 minutes of exercise per day is also recommended, with a good balance between work and rest. Good sleep habits are essential, such as going to bed at a set time.
If one is to use the classical recommendations suggested above, I think in all cases it is important to add one or two heavy mineral substances that settle the spirt and allow yang to descend. These include mu li, long gu, hu po (succinum), ci shi (magnetite) or zhen zhu mu (margaritifera). If there is heat in the heart, shown by a red tip on the tongue, add huang lian, which is very bitter. It is best to administer it as a pill or capsule separately.
There are patent medicines from China that address common presentation of insomnia not included in the above prescribed recommendations. My favorites include the following: any of the Bu Nao Wan or An Mien Wan formulas; Shen Qing Shuai Ruo Wan (available as Shen Ching Shuai Jao Wan) and An Shui Wan. The patent medicines with the heaviest mineral content are the An Shen Bu Xin Wan formulas. I have also found Chai Hu Long Gu Mu Li Wan to be useful for liver stagnation with rising liver yang.
Underlying deficiencies of blood and yin should be addressed, especially in post-menopausal women. Nutritional supplements that are helpful include 5-HTTP, magnesium, gamma-aminobutyric acid and thianine. Acupuncture, addressing the primary pattern, should be given at least once weekly, if possible. It can take several months to control insomnia, and in many cases, it can take one month of treatment for every year that the patient has had the problem.
Long Z, Ed. Traditional Chinese Internal Medicine. Academy Press, 2000, pp. 311-25.
Wu Y, Fischer W. Practical Therapeutics of Traditional Chinese Medicine. Paradigm Publications, 1997, pp. 155-61.
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