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A Case Study on the TCM Treatment of Insomnia

by Dr. Shu-mei Yang¹ & Prof. Kai-chih Chang²

¹China Medical University Hospital, Beigang Branch, Taiwan

² Department of Chinese Medicine, China Medical University, Taiwan

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Insomnia is a frequent complaint of patients who choose to use Chinese Medicine, and is a common sign of psychological and emotional stress.  Despite the fact that insomnia is not a life-threatening problem, it can have a serious effect on a person’s quality of life, and chronic insomnia can lead to anxiety, restlessness, and a decreased resistance to illness.  Aside from negatively affecting a person’s physical health, insomnia can also lead to psychological problems, such as depression.  Consequently, the question of what treatment is most effective for insomnia has become a subject of great importance.

From the viewpoint of Traditional Chinese Medicine, sound sleep is based on harmony between the Zang-Fu organs, Yin/Yang, and Qi/blood.  Causes of insomnia include damage from the seven emotions, pensiveness, excessive fatigue, or fright and anxiety.  Other reasons include a weak constitution, excessive sexual activity, long-term illness, or ageing.  TCM theory says that the liver governs the free flow of Qi, the emotions, and the regulation of the biological rhythms.  Consequently, the manifestation of insomnia is primarily due to mental or emotional frustration, which is a manifestation of liver Qi constraint.  One of the problems that arises when liver Qi is constrained, is that the liver attacks the spleen and weakens the spleen’s ability to transport and transform.

Constrained liver Qi and spleen weakness, which diminishes the body’s ability to generate blood, leads to blood deficiency.  When blood is deficient, the heart lacks nourishment, which can lead to insomnia.  Etiologies, such as external contraction of pathogens or internal damage, can also lead to imbalances in the organs of the heart, liver, gallbladder, spleen, stomach or kidney, which will then result in disturbances to the heart, or the heart becoming deprived of nourishment.  Clinically, positive treatment results can be obtained by treating the cause of the patients’ insomnia along with the addition of herbal medicines that calm and settle the spirit.

Case Study

Name: Mr. Liao	Sex: Male	Age: 67	Marital Status: Married
Height: 168cm	Weight: 62kg	Blood type: A	Occupation: Retired
First Visit: August 21st, 2007		Chief Complaint: Insomnia for one month

 

• History

The patient, a 67-year-old male, had a history of gastric ulcers when he was young, and described himself as a rather anxious person who became nervous easily and was, generally, a light sleeper.  He reported that he began to have difficulty falling asleep and his blood pressure became elevated about a month prior to coming in because of some serious family problems and subsequent anxiety.  Initially, he went to see a physician in the Psychology Department, and was given sedatives and anti-hypertensive medicine.  The medication enabled him to sleep, but the next morning he reported he was extremely tired, his head felt heavy, his mind unclear, and he felt unsteady as he walked.  As a result of such side effects, the patient quit taking his medication after one week, and came to our hospital to seek help.

 

Rehmannia (Di Huang)

The Emperor Herb of Ginseng & Zizyphus Formula (Tian Wang Bu Xin Dan)

•  Symptoms

The patient reported that he perspired easily when the weather was hot, and he occasionally had headaches, his head felt heavy and distended, and his eyes felt sore and dry.  He also said his throat and mouth were dry and his throat would periodically feel ticklish with a desire to cough (with white, thin phlegm).  Other symptoms include bitterness in the mouth, chest oppression, ribside discomfort, and a frequent sensation of inhibited breathing.  He further reported that he had abdominal distention and discomfort after eating with a desire to defecate, his urine was yellow, and he rose 2-3 times every night to urinate.  His main complaint was difficulty falling asleep.  When he fell asleep, he dreamt profusely and woke easily.  After a day of not sleeping well, his neck would become stiff.  The patient’s tongue was dusky and red with a thick, greasy, and yellow coating.  His pulse was floating, wiry, and slightly rapid.

• Diagnosis

Western Medicine Diagnosis: Primary insomnia

Chinese Medicine Diagnosis: Insomnia (Bu Mei)

Diagnostic Principles: Soothe the liver and relieve constraint; fortify the spleen and release dampness; calm the heart and pacify the spirit

 

• Prescription

 

• Treatment Course

The patient’s symptoms had markedly improved after taking the prescription for two weeks.  He reported that he was able to sleep for 4-5 hours each night.  Because the results of treatment were quite good, the patient was given the same prescription for another five weeks.  When the patient’s cough became particularly bothersome, he was given Ma Huang & Morus Formula (Hua Gai San) along with the aforementioned formulas.

 

•  Medicinal Analysis

The primary principles for treating insomnia are to regulate the Zang-Fu organs, Qi/blood, and Yin/Yang.  “Bu Mei” (“not sleeping”) is primarily due to imbalances in the Yin/Yang of the Zang-Fu organs and disharmony between Qi/blood.  The “Ling Shu: Xie Ke Pian” says, “regulate deficiency and excess by supplementing that which is insufficient, and draining that which is excessive.”  This should be a guiding principle with emphasis on the Qi and blood and Yin/Yang of the Zang-Fu organs.

 

In this case, the patient’s overall patterns can be explained as being one of binding constraint of liver Qi with liver and spleen disharmony, and damp-heat causing constraint and obstruction, which disturbs the heart and spirit.  The primary treatment principles are to soothe the liver and relieve constraint, fortify the spleen and release dampness, calm the heart and pacify the spirit.

 

• Formula Analysis

 

 

Conclusion

 

The causes of insomnia are numerous and include the six pathogenic factors, internal damage from the seven emotions, diet, excessive fatigue, and chronic illness.  The etiology is usually one of imbalance in the Zang-Fu organs and debilitation of Qi/blood, which leads to deficiency of right Qi and pathogen repletion.  This leads to a condition, where the heart and spirit lack nourishment, or to a disturbance of the heart-spirit.  The etiology and pathomechanism of insomnia can be classified into various types, and include damage either from the mind and emotions, heart and spleen deficiency, heart and kidney not communicating, blood deficiency with effulgent liver Qi, deficient timidity of heart and gallbladder, internal disturbance of phlegm-heat, or stomach Qi disharmony.  All of the aforementioned patterns can affect the heart-spirit and lead to insomnia.

Clinically, the most common cause of insomnia is some type of mental or emotional stimulation.  It has been said, “Of the illnesses caused by the seven emotions, liver constraint is the most common”.  When in excess, the seven emotions most easily consume the essence of the five Zang organs.  Because the organs are intimately linked via their five phase relationships, when one organ is damaged, it naturally affects another organ.  The liver is the mother of the heart. Therefore, once the liver Qi becomes constrained, it will soon affect the functioning of the heart with signs of palpitation, insomnia, profuse dreaming, and poor memory.  In addition, emotional dissatisfaction or negative mental stimulation often lead to liver Qi constraint, and eventually may cause liver and spleen disharmony with stagnation, and damp-heat obstruction that disturbs the heart and causes insomnia.

When a patient comes for treatment, it is very important to determine what are the causes of their insomnia.  If the patient’s insomnia is the result of some emotional problems, then the location of the imbalance most likely includes the liver, heart, and spleen; the emphasis of treatment should be on the liver.  In such cases, the treatment will only be successful if we use herbal extracts to soothe the liver and resolve constraint.  In addition, herbal extracts that sedate and calm the spirit can be added to the prescription.

Insomnia is a sign of heart-spirit pathology; in addition to treating with herbal extracts, it is also very important to take into consideration the mental health of the patient in order to help them resolve the emotional issues leading to their sleep problems.  Other important factors for treating insomnia include avoiding stimulating drinks, like tea and coffee, before going to bed, as well as waking, eating and resting regularly.  It is very important to educate patients proper sleep hygiene to obtain optimal treatment results.

Commonly Used Formulas for Treating Insomnia