Insomnia is a morbid state characterized by an inability to sleep. The condition may vary in severity and manifest itself as difficulty in falling asleep, waking up easily after falling asleep, falling asleep in shallow degree or intermittently or with nightmares, or inability to sleep in shallow degree or intermittently or with nightmares, or inability to sleep for the whole night or several nights. Clinically, insomnia may occur individually or be accompanied by the manifestations of headache, dizziness, palpitations, amnesia, etc.

Cases of neurosis, climacteric syndrome and anemia with insomnia as the major symptom may be differentiated and treated with the principles mentioned in this section.

Etiology and Pathogenesis

Insomnia may result from emotional upsets, overstrain, immoderate diet and drinking, debility or longstanding illness. Its pathogenesis may be summarized as: (1) the damage of heart and spleen; (2) functional imbalance of the hart of kidneys; (3) the stagnated qi changing into fire; (4) flaming-up of liver-yang due to yin-deficiency and fire-hyperactivity; (5) deficiency of heart-qi and gallbladder-qi due to fear; (6) phlegm-heat due to the accumulation of food; and (7) the disorder of stomach-qi resulting in the derangement of heart and mind.

Syndrome Differentiation and Therapeutic Principles

A. Syndrome differentiation

(a) Identification of the characteristics of insomnia: In general, any case with difficulty in falling asleep shows the presence of fire which should be distinguished into asthenia and sthenic fire. A shallow sleep usually signifies the coexistence of asthenic and sthenic fire. Waking up easily after falling asleep or inability to sleep for the whole night is generally attributed to an asthenia-syndrome, particularly deficiency of heart and spleen.

(b) Differentiation between asthenia and sthenia syndromes: A long-standing case usually manifests itself as an asthenia-syndrome resulting from insufficiency of yin-blood and involving the heart, spleen, liver and kidneys, and the common types are the blood and qi as well as yin deficiency and fire hyperactivity. While a newly affected case frequently manifests itself as a sthenia-syndrome attributed to an interior attack of fire and involving the heart, spleen, liver and stomach, and the phlegm-heat formed by the retention of food as well as the stagnated liver-qi changing into fire are the common types.

B. Therapeutic principles

For asthenia-syndrome, the therapy of tonifying the liver and kidneys, benefiting qi and nourishing blood should be used; and for sthenia-syndrome, that of relieving dyspepsia and regulating middle jiao, clearing away fire and eliminating phlegm ought to be adopted. Moreover, drugs for tranquilizing may be added selectively, e.g., the drugs for calming the liver and suppressing yang such as Os Draconis, Dens Draconis, Magnetitum, etc., those for calming the heart such as Cinnabaris, those for reliving terror such as Succinum and those for nourishing the heart such as Semen Ziziphi Spinosae, Semen Biotae, Caulis Polygoni Multiflori, etc.

Classification and Treatment

A. Sthenia-syndrome

(a) Stagnated liver-qi changing into fire

Manifestations: Difficulty in falling asleep with a lot of nightmares, irritability, redness of eyes, bitter taste in the mouth, thirst with desire for drink, poor appetite, dark yellow urine, constipation, red tongue with yellow coating and wiry and rapid pulse.

Therapeutic principles: Disperse stagnated liver-qi, eliminate heat, and calm the mind.

Prescription: The Modified Decoction of Gentianae for Purging Liver-Fire

Radix Gentianae 9 g
Radix Scutellariae 10 g
Radix Bupleuri 10 g
Radix Paeoniae Alba 10 g
Fructus Gardeniae 9 g
Radix Curcumae 10 g
Rhizoma Cyperi 10 g
Pericarpium Citri Reticulatae 10 g
Radix Rehmanniae 10 g
Os Draconis Usta (decocted first) 30 g
Concha Margaritifera Usta (decocted first) 30 g

(b) Retention of phlegm-heat in the interior

Manifestations: Difficulty in falling asleep or shallow sleep usually induced by immoderate diet and drinking, heavy sensation over the head, dizziness, abundant expectoration, oppressive feeling over the chest, anorexia, acid eructation, nausea, vexation, bitter taste in the mouth, yellow greasy tongue coating and smooth and rapid pulse.

Therapeutic principles: Eliminate phlegm, clear away heat, regulate middle jiao, and calm the mind.

Prescription: The Modified Decoction for Clearing Away Gallbaldder-heat

Poria 15 g
Exocarpium Citri Grandis 10 g
Rhizoma Pinelliae 10 g
Caulis Bambusae in Taeniam 10 g
Rhizoma Coptidis 5 g
Fructus Gardeniae 10 g
Fructus Aurantii Immaturus 10 g
Fructus Crataegi Carbonisatus 10 g
Fructus Hordei Germinatus Carbonisatus 10 g
Fructus Oryzae Germinatus Carbonisatus 10 g

Remarks: For cases with constipation due to severe attack of phlegm-heat, add Radix et Rhizoma Rhei and Fructus Trichosanthis to purge fire, eliminate phlegm and calm the mind.

B. Asthenia-syndrome

(a) Yin-deficiency and fire-hyperactivity

Manifestations: Restlessness, difficulty in falling asleep, palpitations, dizziness, tinnitus, amnesia, feverish sensation over palms, soles and the chest, lumbago, nocturnal emissions, dryness of mouth, red tongue and thready and rapid pulse.

Therapeutic principles: Supress fire, nourish the heart, and calm the mind.

Prescription: The Modified Decoction of Coptidis and Colla Corii Asini

Rhizoma Coptidis 5-9 g
Colla Corii Asini 10 g
Radix Scutellariae 10 g
Radix Paeoniae Alba 12 g
Radix Rehmanniae 12 g
Radix Ophiopogonis 12 g
Fructus Schisandrae 6-10 g
Dens Draconis (decocted first) 30 g
Semen Ziziphi Spinosae (fried) 15 g

(b) Deficiency of the heart and spleen

Manifestations: Dreaming and waking easily after falling asleep, palpitations, amenia, dizziness, fatigue, spiritlessness, loss of appetite, lusterless complexion, pale tongue with thin white coating and thready and rapid pulse.

Therapeutic principles: Nourish the heart and spleen, and calm the mind.

Prescription: The Modified Decoction for Invigorating the Spleen and Nourishing the Heart

Radix Codonopsis Pilosulae 12 g
Rhizoma Atractylodis Macrocephalae 10 g
Radix Astragali Praeparata 12 g
Radix Angelicae Sinensis 10 g
Lignum Pini Poriaferum 10 g
Radix Aucklandiae 6 g
Semen Ziziphi Spinosae (fried) 15 g
Radix Polygalae 10 g
Arillus Longan 10 g
Radix Glycyrrhizae Praeparata 6 g
Caulis Polygoni Multiflori 30 g
Pericarpium Citri Reticulatae 10 g

Remarks: For cases with palpitations, shortness of breath and sallow complexion, add Colla Corii Asini, Radix Rehmanniae Praeparata and Radix Paeoniae Alba to nourish blood and calm the mind. For cases with oppression in the epigastrium, poor appetite, abdominal distention and diarrhea, add Rhizoma Pinelliae and Cortex Magnoliae Officinalis to tonify spleen and eliminate dampness. For serious cases of insomnia with dreamfulness, add Semen Biotae, Fructus Schisandrae to nourish the heart and calm the mind or add Dens Draconis, Concha Ostreae and Concha Margaritifera Usta to enhance the sedative effect.

C. Deficiency of hear-qi and gallbaladder-qi

Manifestations: Waking easily and dreamfulness, timidness, palpitations, spiritlessness, fatigue, spontaneous perspirations, shortness of breath, pale tongue and wiry and thready pulse.

Therapeutic principles: Benefit qi, and calm the mind.

Prescription: The Modification of Tranquilizing Pill

Radix Codonopsis Pilosulae 12 g
Lignum Pini Poriaferum 10 g
Radix Polygalae 10 g
Radix Glycyrrhizae Praeparata 6 g
Rhizoma Acori Graminei 10 g
Ramulus Cinnamomi 5 g
Semen Ziziphi Spinosae (fried) 15 g
Dens Draconis (decocted first) 30 g

In addition, the Modified Decoction of Invigorating the Spleen and Nourishing the Heart may be applied to tonify blood and calm the mind for the cases with insufficient qi and blood which occur in the aged or the debilitated after illness and manifest itself as restlessness, emaciaton, pale complexion, mental fatigue, pale tongue and thready and weak pulse.

Jiaotai Pill composed of Pulvis Rhizoma Coptidis (3 g) and Pulvis Cortex Cinnamomi (1.5 g) may be applied to cases with flaming-up of the heart-fire and deficiency of kidney-yin.

Moreover, aside from medications, mental and life care is also important for the treatment of insomnia, such as relief of Anxiety, avoidance of mental stress, adoption of physical training, abstinence from smoking, drinking, strong tea, overeating, etc.

Experiential Prescription

A. Radix Salviae Miltiorrhizae (60 g) and brown sugar; prepared as decoction over low fire; one dose every night.

B. Semen Ziziphi Spinosae (30 g, fried), Fructus Schisandrae (6 g) and Caulis Polygoni Multiflori (15 g); prepared as decoction; taken daily in two divided doses; applicable to cases of insomnia due to blood deficiency.

C. Poria (15 g) prepared as decoction and mixed with one fresh egg yolk; taken orally before bedtime; applicable to the cases of insomnia with asthenia-syndrome.

Copyright 1995 Hopkins Technology