Help for Insomnia – with Chinese Medicine Herbs and Acupuncture

Every living organism on the planet needs sleep. It is an integral component of health. A sufficient amount of good quality, restful sleep is essential to prevent illness as well as cultivate health and facilitate longevity.

The desire to sleep – without being able to – is one of the most frustrating experiences in modern existence. Those who suffer from this affliction may stare up at the ceiling when they go to bed, be unable to fall asleep right away, or wake in the middle of the night with their mind racing with random thoughts. Or they may experience restless sleep with tossing and turning throughout the night.

Of course, most people will have occasional sleepless nights during their life, but for some insomnia can become chronic. Chronic insomnia – defined as having difficulty sleeping several times a week for several months – can severely disrupt a person’s life and adversely affect their wellbeing. This lack of rest puts a damper over a person’s mood, affecting their quality of life, and can turn sleep into a chore that they dread instead of a relieving opportunity to rest and recover.

The general medical consensus is that seven to nine hours of sleep is the appropriate amount to support optimal health in adults. According to a poll in 2013, the average American was sleeping 6.8 hours at night, down more than an hour from 1942; 59 per cent were getting the minimum amount of sleep, whereas 40 per cent were getting less than seven hours. In comparison, 70 years ago 84 per cent of people were obtaining the required amount of sleep. Prior to the coronavirus pandemic, approximately one in ten adults had chronic insomnia, and the prevalence was one in three for those visiting their general physician.

According to a recently published Canadian study, the pandemic has severely disrupted sleep in 51 per cent of people. Those interviewed also reported having higher levels of stress and increased reliance on medication. Other researchers found that approximately 34 per cent of patients experienced at least one neurological or psychiatric symptom in the six months following a confirmed diagnosis of COVID-19. The study’s data showed insomnia may be one of the most common sequelae of COVID-19 (based on the health records of 236,000 patients who tested positive and survived). The incidence of insomnia was found to increase with greater infection severity and hospitalisation. The sleep difficulties being reported during the pandemic are not only in people recovering from COVID-19, but also in the far larger number of people worldwide whose lives have been turned upside down due to fear of becoming ill and dying as well as the effects of social isolation due to lockdown. Following this increase, neurologists who specialise in sleep disorders have developed the term ‘COVID-somnia’.

Almost all patients coming to my clinic over the last two years have been complaining of poor sleep, no matter what other problems they might present with. It is important to note that recent research on insomnia, such as the Canadian survey referred to above, was completed towards the beginning of the pandemic, when the number of cases and deaths per capita were relatively low. Based on research showing the negative consequences of ongoing isolation and lack of social interaction, these numbers are likely to continue to worsen. According to a recent study in The Lancet, periods of isolation of even less than 10 days can have long-term effects, resulting in psychiatric symptoms up to three years later. The psychological consequences of the stress of the pandemic are already apparent, with anxiety and panic, obsessive-compulsive symptoms, insomnia, digestive problems, depressive symptoms and post-traumatic stress increasing greatly.

A recent report from the American Academy of Sleep Medicine indicated that 56 per cent of those surveyed had experienced an increase in sleep disturbance, which increased to 70 per cent in those aged 35 to 44 years old. Fifty-one per cent of these participants reported using sleep medication, over-the-counter supplements or other substances to help them fall asleep, and 68 per cent acknowledged increased use of these aids during the pandemic. Unfortunately, the consequences of these changes have yet to reach their peak and will long outlive the current pandemic. The potential for long-term mental health problems including anxiety, depression and further impacts of insomnia (especially if it becomes chronic) are significant. The resulting overuse of prescription sleep medication is also concerning.

Whilst obtaining peaceful, restorative sleep on a nightly basis can alleviate daily stress, persistent stress is shown to contribute to chronic insomnia, especially in those who have a personal or family history of difficulty sleeping. The main stressors identified in sleep research include problems or dissatisfaction at work, divorce and other marital or family difficulties, death of a loved one, major illness or injury, or crucial life changes. In modern society the prevalence of insomnia and the use of sleep medication have increased substantially over the years.

Sleep Medication: A Modern Medical Approach to Insomnia

Despite the well-documented side-effects and limited effectiveness of sleep drugs, they are still by far the most common treatment provided by medical doctors for insomnia. Studies have found consistently rising rates of sleep aid use over the years, with one study using data from 1999-2010 estimating that around 19 per cent of adults had used a form of sleep medication at least once in the previous month.

During 2017–2018, statistics from the Centers for Disease Control (CDC) in the United States revealed that more than eight per cent of adults used a sleep aid at least four times in the previous week. Reviewing the accessible medical research reveals that the benefits of sleep medication is smaller and the risks greater than might be expected. Sleep-promoting medications are not safe and are generally only recommended as a short-term solution for fleeting cases of insomnia; it is advised that they should be used for no more than two weeks.

The first confirmed death due to COVID-19 in the United States was in February 2020 and the total number of cases by March 1st 2020 was 66 cases. Despite these low numbers at the time, between mid-February and mid-March 2020 there had already been a 14.8 per cent increase in sleep medication prescriptions compared with the same period the previous year. A year later the total number of COVID-19 cases in the United States has exceeded more than 75 million, with close to nine hundred thousand deaths. Globally, the stress of the pandemic has continued to increase and thereby adversely affect people’s health and well-being. Based on these initial studies, future research will likely demonstrate prevalence of COVID-somnia and medication use proportional to the severity and duration of the pandemic.

Stress, Cortisol and Sleep

Cortisol is often called the ‘stress hormone’ because it is a key component of the body’s natural ‘flight or fight’ response. In the modern world, this response – that once gave our ancestors the short-term speed and endurance needed to escape life-threatening danger – tends to be constantly activated. For many people, and especially during the coronavirus pandemic, the stress of life does not let up. Many people harbour resentment, fear and anxiety, and worry about daily events and relationships.

The hypothalamus– pituitary–adrenal (HPA) axis responds to these thoughts and feelings by releasing cortisol into the blood stream. The result is stress hormones continuously circulating through the body at high levels, never leaving the blood and tissues.

Blood levels of cortisol vary throughout the day, following a diurnal rhythm. Based on this, levels of cortisol should be lowest at midnight and gradually start to rise to their highest level around 8 am. As soon as this peak is achieved, the levels gradually decline and by the evening and during the early phase of sleep they drop very low. Similar to yin and yang, the sleep hormone melatonin works together with cortisol within the HPA axis to regulate sleep and wakefulness. If cortisol levels stay high at bedtime then the body will not optimise the release of melatonin, which can adversely affect sleep.

At appropriate levels, cortisol regulates blood pressure and blood sugar, strengthens the heart muscle, improves memory, boosts the immune system and lowers sensitivity to pain. In normal conditions, cortisol levels increase approximately fifteen minutes after the onset of fear or stress, and stay elevated for several hours after. The body’s stress-response system is usually self-limiting and once a perceived threat has passed, the hypothalamus will signal for the body to stop producing cortisol. With the drop in adrenaline and cortisol levels, the heart rate and blood pressure return to baseline levels, and other systems resume their regular activities. However, if continuous stress is perceived to be present, the hypothalamus continues to send messages to the pituitary gland to tell the adrenal glands to continue producing cortisol, which at this stage begins to be neurotoxic and poisonous to the brain.

Chronic stress (as well as repeated traumas) can result in a number of biological reactions that cause a cascade of changes in attention, impulse control, sleep and fine motor control. High levels of cortisol have been shown to be involved in numerous physical problems, including obesity, blood sugar imbalances including diabetes, decreases in muscle tissue and bone density, digestive problems, heart disease, stroke and high blood pressure. High levels can also make the body more susceptible to disease by lowering immunity, leading to higher likelihood of infection and longer recovery time; this is a very important factor in the context of the current pandemic.

From a modern medical research perspective it is unclear whether elevated cortisol is more a cause or a consequence of insomnia. Sleep deprivation does lead to increased levels of cortisol, which are elevated even further if a person experiences increased stress throughout the day. Equally, when stress causes a surge in adrenaline and cortisol this leads to increased alertness, making it more difficult to relax into sound sleep at night.

The current pandemic is causing constant stress for many and thus elevating the levels of these hormones. When the hormones remain high, or rise and fall irregularly through the night, this causes the person to be in a hyper-vigilant state that is incompatible with restful sleep. Research strongly suggests a role for cortisol as a sleep disruptor due to the correlation of heightened HPA-axis activity to restless, interrupted sleep, shallow sleep and decreased length of sleep. Other studies have shown that sleep deprivation is linked to higher cortisol levels and to a more extreme adrenal response in the presence of stress. From a TCM point of view, these hormonal responses are particularly associated with Liver depression qi stagnation.

Liver Depression ~ Qi Stagnation

The effects of stress have been noted in Chinese medical literature for over two millennia. During this time, effective ways of diagnosing, treating and preventing health problems associated with stress have been established. This includes a long history of diagnosing and treating disease resulting from the stress and fear caused by epidemics. Since ancient times, epidemics have been a central topic in Chinese medical thought. According to Dr. John Chen there have been over 320 large-scale epidemics in China in the last 2,000 years.

According to Traditional Chinese Medicine (TCM) theory, a person is healthy when qi is sufficient in quantity and flowing freely. The organ responsible for free flow of qi is the Liver. In TCM it is said that ‘the Liver is the temperamental organ’, meaning that it is typically the first organ to be negatively affected by mental-emotional stress. If the Liver is negatively influenced by frustration, suppressed emotion, or stress its function of promoting free-flow is affected.

This is further exacerbated if a person has not learned healthy ways to process his or her emotions and does not participate in activities that promote flow of qi in the body (i.e. physical activity, social connection with loving relationships, relaxation/meditation, singing/chanting, laughing, finding meaning or purpose in life, etc.).

The restrictions brought about by the pandemic have had a deleterious effect on people’s health. During the pandemic, people have experienced more unfulfilled desires than usual due to a lack of social connection, job losses, limited physical exercise, financial difficulties, and loss of loved ones.

Humans are social beings and naturally desire connection with others. If this desire to connect is not fulfilled due to prolonged social isolation imposed by government restrictions, mental health problems can be triggered, leading to Liver depression qi stagnation. The imbalance caused by unfulfilled desires is so common that TCM doctors coined the phrase: ‘In adults, blame the Liver’, which emphasizes the importance of the Liver in the treatment of pathology in adults.

Further, there has been a significant rise in separations and divorces. These are known to be a trigger for the development of mental health problems including depression, anxiety, and insomnia. Past research has demonstrated that isolation is associated with cognitive impairment, reduced immunity, increased risk of cardiovascular disease and, ultimately, mortality.

If the Liver qi does not flow freely, it will tend to back up and accumulate, manifesting initially as fullness and distension in the areas traversed by the Liver and/or Gall Bladder channels. In addition, dysfunction of the Liver’s coursing and discharging function is often reflected in the emotions and digestion, as well as menstruation in women.

Liver depression qi stagnation – usually manifests with the following common symptoms:
• Chest, rib, breast, abdominal distension and oppression
• Upper back, neck or shoulder tension
• Irregular and/or painful menstruation, PMS
• Tendency to sigh
• Irritability, propensity to anger
• Mental depression, dull affect, taciturnity
• Cold hands (especially when nervous/stressed)
• Alternating diarrhoea and constipation, small pellet-like stools, or incomplete bowel movements
• Headache in the temple and forehead regions
• Normal or darkish tongue with thin white coating
• Wiry/bowstring pulse

When unable to cope with stress, people consciously or unconsciously try to relieve the build-up of pressure by ‘self-medicating’. This may manifest as increased consumption of (and then becoming addicted to) coffee, alcohol, drugs, sugar or cigarettes, or engaging in other risky behaviours that temporarily move the stagnant qi and make them feel better. In extreme circumstances the inability to deal with pressure and stress can even lead to suicide. Suicide and addiction have noticeably increased during the pandemic. Unfortunately, addictions weaken the body, making the person more susceptible to stress and stagnation in the future, which in turn can lead to more severe addiction, as the person requires more of the same substance to feel relief. Of course, many of these substances are in themselves enemies of obtaining a restful night sleep.

Acupuncture is very effective at moving qi and restoring the function of the Liver, and is often an effective treatment for stress-related disorders, including insomnia. Essential oils can also be helpful to move qi, are cost effective and can be combined with the main treatment of herbal medicine as a daily home treatment. Recently, I have developed a blend of TCM essential oils based on research in China that is very helpful to treat qi stagnation in patients with COVIDsomnia and/or depression and anxiety.

While Liver depression qi stagnation contributes to difficulty sleeping, poor sleep can inhibit the Liver from maintaining homeostasis in response to changing conditions, causing further qi stagnation. Liver depression qi stagnation-type insomnia typically worsens with stress , emotional upset and pre-menstrually, with sleep tending to be light and the person being easily awoken or experiencing vivid, dream disturbed sleep and waking in the early hours. However, in clinical practice sleep is only disturbed when this pattern co-exists with other TCM patterns that must be accurately diagnosed and simultaneously treated by the TCM practitioner to ensure a successful clinical outcome.

In TCM, depressive heat due to qi stagnation causes the body-mind to become over-heated leading to restlessness, which prevents the person sleeping or causes them to wake in the night.

Depressive Heat

The qi of the body is yang and therefore warm; if the qi becomes stagnant and accumulates it may transform into heat.   There is a quote in TCM that say ‘Emotions are deleterious to health [only] when they are excessive and prolonged. When excessive, [any &] all seven emotions [may] transform into fire.’ This illustrates that when qi stagnation is severe or prolonged it can eventually transform into depressive heat/fire of the liver . I check for this pattern in every patient due to its high rate of occurrence, especially in COVID-somnia patients.

When pathological heat is generated it moves upwards in the body to affect the function of the organs and tissues above the Liver: the Heart, Lung, head, mouth, nose, eyes and ears.

When heat/fire harasses the Heart and therefore the spirit and mind in TCM it causes insomnia, including difficulty falling asleep, frequently and easily being awakened, difficulty falling back to sleep and profuse dreams or nightmares that disturb sleep.

Common clinical signs and symptoms of depressive heat in the Liver include signs and symptoms of Liver depression qi stagnation (listed above) plus some of the following:

• Irascibility (could include explosive, violent outbursts of anger, cursing, shouting and physically throwing or destroying things) • Impetuosity • Heart vexation (irritable hot sensation in the upper abdomen and/or chest) • Breast distension (including pain and hypersensitivity) • Early or excessive menstruation • Bitter taste in the mouth (especially upon waking in the morning) • Wiry, rapid pulse • Red tongue (may be just the sides) with yellow coating • Easily flushed when nervous/stressed, or with alcohol or exercise • Insomnia, especially waking between 2am and 4am, worse when stressed

If heat/fire rises to the Heart (and spirit and mind) there may be insomnia, profuse dreams, heart palpitations, mental restlessness and anxiety, vexatious heat in the chest, sores in the mouth or on the tip of the tongue and painful and scanty dark-coloured urination; the patient often wakes between 11pm and 1am feeling hot and agitated and is unable to get back to sleep.

If heat rises to the head there can be red, inflamed skin problems (including acne, rosacea, seborrheic dermatitis and perioral dermatitis), dry mouth, thirst, red eyes and complexion, dizziness/vertigo, tinnitus, painful ears, headache with distension (on the side of the head or temples and often one sided), and a red tongue with yellow coating.

TCM Approach to Treating Insomnia

TCM (more often than not) is superior to modern medicine in the treatment of chronic diseases including insomnia. Specifically, Chinese Herbal Medicine and acupuncture can offer substantial clinical benefits to patients who have been unresponsive to other forms of treatment.

Acupuncture – is effective at moving qi and restoring the function of the Liver, and is often a good treatment for stress-related disorders, including insomnia. Essential oils can also be helpful to move qi, are cost effective, and can be combined with treatment by herbal medicine as a daily home practice. Recently, I have developed a blend of TCM essential oils based on research in China that is helpful to treat qi stagnation in patients with COVIDsomnia and/or depression and anxiety.

While Liver depression qi stagnation contributes to difficulty sleeping, poor sleep can inhibit the Liver from maintaining homeostasis in response to changing conditions, causing further qi stagnation. Liver depression qi stagnation-type insomnia typically worsens with stress, emotional upset, and pre-menstrually, with sleep tending to be light and the person being easily awoken or experiencing vivid, dream-disturbed sleep and waking in the early hours. However, in practice sleep is only disturbed when this pattern co-exists with other TCM patterns that must be accurately diagnosed and simultaneously treated by the TCM practitioner to ensure a successful outcome.

In TCM, depressive heat due to qi stagnation causes the body-mind to become over-heated leading to restlessness, which prevents the person sleeping or causes them to wake in the night.

Chinese Herbal Medicine – is the most sophisticated herbal medicine system in the world and has always been considered pre-eminent amongst the various methods of healing within TCM. More than 100 generations of doctors over thousands of years have carefully observed patterns of illness and have used powerful natural remedies to alleviate these conditions and restore and maintain good health.

TCM combines a detailed analysis of signs and symptoms with a unique system of pulse and tongue diagnosis to develop a detailed picture of the course and process of disease. After diagnosis each person will typically be prescribed an individual herbal tea, using combinations of 10 to 15 ingredients correlated to an individual’s pattern of internal disharmony. The patient will then decoct or cook these medicinals in water and take the resulting liquid/medicine twice daily.

• Base Herbal formulas used to treat liver disharmony:
  Dan Zhi Xiao Yao San (Augmented Rambling Powder)
  Xiao Chai Hu Tang (Minor Bupleurum Decoction);
  Chai Hu Jia Long Gu Mu Li Tang (Bupleurum Plus Dragon Bone and Oyster Shell Decoction)
  Long Dan Xie Gan Tang (Gentiana Decoction to Drain the Liver)
• Common Herbs to course the Liver and move the qi:
  Chai Hu (Bupleuri Radix)
  He Huan Pi (Albiziae Cortex)
  Xiang Fu (Cyperi Rhizoma)
  Yuan Zhi (Polygalae Radix)
  Yu Jin (Curcumae Radix)

These medicinals are chosen and combined depending on the symptoms and co-existing patterns the patient has. In general, I would employ two, three or four of these per prescription if Liver depression qi stagnation was present depending on the severity and presenting symptoms and whether it was currently the predominant pattern or not.

The formulas are crafted together to act synergistically, and every ingredient is designed to accomplish a part of the overall process of restoring balance. Upon return visits, the herbal formula is adjusted or modified by the practitioner as the patient’s condition improves. When prescribed and dispensed by a qualified practitioner of TCM, Chinese Herbal Medicine is safe with no side-effects.

Modern research into acupuncture and various Chinese herbs has shown it to have fewer side effects. And unlike modern medicine, acupuncture and herbs are curative not palliative, as they aim to eliminate the pathology of the disease instead of controlling or suppressing the symptoms.

Chinese medicine is therefore a viable alternative to Western medicine for treatment of insomnia. Insomnia drugs are among the most widely prescribed in the world today and are increasingly being prescribed during the pandemic to help people cope with the increased stress they are experiencing. Yet these drugs have limited effectiveness and significant side effects.

Any long-term treatment of a disease has to have properties that will make the user want to continue using it. That means it must be:
• Effective and provide relief of symptoms
• Safe, with few unwanted side effects
• Easy to use

TCM, when prescribed correctly, can meet all of these criteria and can help you obtain the calm, restful and restorative sleep you require to maintain your optimal level of health.

Look for Robert’s upcoming guest post on “20 Tips to Obtain Peaceful Restorative Sleep During and After a Pandemic” next month.