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Traditional Chinese Medicine Approach to Treating Sleeping Problems
Research Practicum
2005
by
Kerry Dyer
Hello everyone. Thank you for attending my talk on treating sleep disorders with Traditional Chinese
Medicine. My name is Kerry Dyer. I am a Licensed Acupuncturist and Licensed Massage Practitioner. I am a
graduate of the Oregon College of Oriental Medicine with my Masters in Acupuncture and Oriental Medicine. I
also received my Bachelor of Arts through the University of Alaska Anchorage and my massage training from
East West College of the Healing Arts. I was drawn to Traditional Chinese Medicine and complimentary
healing for many reasons, but my overall reason for entering this field is to assist people in their healing in an
effective and compassionate manner with a holistic approach to the body, mind, and spirit. I am passionate
about this medicine and dedicated to helping myself as well as others on our paths of well-being and healing.
Today I am going to talk about sleeping problems and what Traditional Chinese Medicine has to offer
people with such problems. I will describe the prevalence of sleeping problems in our country and other nations.
I will describe sleep cycles and common medical diagnoses and treatments for sleep problems. I will then give a
brief history of TCM, Traditional Chinese Medicine, discuss some of the theory behind TCM, and discuss how
TCM can help treat sleeping problems using acupuncture, acupressure, massage, and herbs. I will also describe
what a TCM visit may be like for someone suffering from a sleep problem. If you have any questions feel free
to ask them during or after the talk.
For all of us to have an overall sense of well-being it is vitally important to have a restful sleep. The
requirements for a restful sleep are different for each person, however many people in our country and the
world suffer from sleep problems. The Merck Manual states sleep is essential in our lives; however, individual
requirements vary greatly from 4 to 10 hours of sleep in healthy persons. Factors to consider when deciding if
there are problems with sleep are a person’s emotional states, age, length of sleep, and quality of sleep. (Merck
Manual, 17ed, 1999)
Results from the National Sleep Foundation’s 2005 Sleep in America Poll, found that an average adult
living in the United States sleeps 6.8 hours a night on weekdays and 7.4 hours on weekends. Only 49% of
people reported having a “good night’s sleep” often or every night. People stated they needed a minimum of 6.5
hours of sleep to function their best the next day. The poll showed that within the past year or a few nights a
week, 75% of adults had at least one symptom of a sleep problem such as; difficulty falling asleep, maintaining
sleep, waking early, snoring, restless legs, pauses in breathing, and inability to resume sleep once awake.
However, 76% of adults polled did not believe they had a sleep problem. Highlights from the 2004 Sleep in
America Poll found that 69% of children have one or more sleep problems weekly and many infants, toddlers,
and preschoolers appear overtired during the day. The 2003 Sleep in America Poll found sleeping problems in
adults, aged 55 to 84 years old, are often secondary to other health problems and not necessarily due to aging.
However, 83% of participants interviewed by phone reported one or more medical conditions. Also, 25% of
persons aged 65 to 84 years experienced four or more major medical problems. Other medical problems,
including body pain and obesity, were associated with sleep disturbances and reduced sleep quality, including
snoring, daytime sleepiness, and restless legs. (Foley, 2003) Stanford University Sleep Epidemiology Research
Center interviewed about 8000 United Kingdom (UK) subjects, over the age of 55, by phone. Results showed
chronic diseases, anxiety and other mental health problems, lack of exercise, use of caffeine, and use of sleeping
medications were associated with sleeping problems. The average sleep time in the UK was 6 hours and 57
minutes. (Ohayon, 2004)
During the last few decades, to better understand why some people sleep well and other don’t,
researchers have learned a lot about our sleep and sleep-wake cycles. In general there are two main types of
sleep, rapid eye movement (REM) and non-rapid eye movement (NREM). They are often monitored by using
an EEG and monitoring eye movements. An EEG monitors brain activity and can measure specific brain waves.
During a typical sleep cycle NREM initiates the sleep and consists of slow waves ranging in depth. Four stages
of NREM occur, such as stage 1 which accounts for 5% of our sleep and is the transitional stage from
wakefulness to sleep, stage 2 occupies 50% of our sleep and displays certain EEG waves such as sleep spindles
and K complexes, stages 3 and 4 occupy about 10 to 20% of our sleep and are the deepest sleep levels. Stages 3
and 4 are also known as slow-wave sleep. (DSM IV, 4ed, 1994) During NREM sleep breathing and heart rates
slow, blood pressure lowers, and muscle tone softens. NREM type of sleep makes up most of our cycle, about
75% of our sleep time. REM sleep, on the other hand, causes low voltage, but fast activity on the EEG. During
REM sleep muscles soften even more while respiration depth and rates vary and dreams occur. REM occurs
about every 90 to 120 minutes and follows NREM sleep. For every four to six cycles of NREM sleep, we will
have one cycle of REM. (Merck Manual, 17ed, 1999) REM sleep also increases towards the morning (DSM IV,
4ed, 1994)
Sleep in general varies through our lives, with larger amounts of slow-wave sleep in childhood and
adolescence while in later adulthood a decrease in these NREM stages of 3 and 4. As we age our sleep is
thought to become lighter and less continuous, with an increase in wakefulness and Stage 1 sleep. Also, when a
person is sleep deprived, NREM stages 3 and 4, which usually occur in the first half of the night, will increase
in length. Individuals at risk for sleep disorders are often assessed due to their chief complaints of sleep
problems. An assessment may include an evaluation of their sleeping problem, consideration of mental health
disorders, consideration of general health and other medical problems, and any supplements or medications that
may be causing a sleep problem. Sleep labs and other tests may also be done to help assess the person’s sleep
complaint. (DSM IV, 4ed, 1994)
Sleep labs have become very popular to assist in diagnosing a person’s sleep problem or other medical
problems. Sleep labs monitor the sleep stages in the patient through polysomnographic measures using an EEG
to monitor brain waves, as well as other equipment to monitor eye movements, oxygen levels, muscle tone, and
heart rate. Testing is usually done at night, however information can be gathered during the day. Daytime
sleepiness may also be measured using a test such as the Multiple Sleep Latency Test (MLST). The MLST
patient will lie down in a dark room five times a day without resisting falling asleep. The time it takes the
person to fall asleep is measured and considered as the time it takes the person to fall asleep. The Repeated Test
of Sustained Wakefulness (RTSW) can also be used. The RTSW patient is asked to lie in a dark room several
times a day and remain awake. The time it takes for a person to fall asleep is again measured, but this time it is
the person’s ability to maintain wakefulness that is considered. (DSM IV, 4ed, 1994) Many forms of testing
exist to measure and assess a person’s sleep, as well as many categories of sleeping disorders.
According to the DSM IV, sleeping disorders make up four main groups according to the etiology, or
cause, of the disorder. These four groups include: Primary Sleep Disorders which include Dyssomnias and
Parasomnias, Sleep Disorder Related to Another Mental Disorder, Sleep Disorder Due to a General Medical
Condition, and Substance-Induced Sleep Disorder. (DSM IV, 4ed, 1994)
Primary Sleep Disorders are those without a cause due to mental disorders, general medical conditions,
or substance and medication usage. These types of disorders are believed to be due to an internal problem
regulating their sleep and wake cycle. (DSM IV, 4ed, 1994)
Dyssomnias are a type of Primary Sleep Disorder which includes problems in the length, depth, and time
of sleeping. Included in Dyssomnias are: Primary Insomnia, Primary Hypersomnia, Narcolepsy, BreathingRelated Sleep Disorder, Circadian Rhythm Sleep Disorder, and Dyssomnia Not Otherwise Specified.
Parasomnias are also a type of Primary Sleep Disorder which include a sleep complaint occurring with
behavioral or body problems. Sleep Disorder Related to Another Mental Disorder includes a sleep complaint
resulting from a diagnosed mental disorder. Sleep Disorder Due to a General Medical Condition includes a
sleep complaint resulting from a medical condition. Substance-Induced Sleep Disorder includes a sleep
complaint resulting from present or past use of a substance, such as medications. (DSM IV, 4ed, 1994)
To assess and diagnosis a sleep complaint, certain criteria must be met. A qualified health practitioner,
such as a medical doctor, psychologist, nurse practitioner, or licensed clinical social worker, can determine if
criteria is appropriately met and make such a diagnosis. An example of some diagnostic features of a Primary
Sleep Disorder of Primary Insomnia include: a sleep complaint for at least one month of non-restful sleep,
problems initiating sleep, problems maintaining sleep, and distress in other areas of one’s life, such as work,
etc., due to sleep problems. Also, as stated earlier, for a person to be diagnosed with any type of Primary Sleep
Disorder, the other three main types of sleeping disorders must be ruled out. The person may also have mental
health concerns that do not fit into a particular mental health diagnosis, yet if sleep does not improve a later
mental health diagnosis, such as an Anxiety Disorder, may occur possibly due to continued lack of sleep.
Primary Insomnia must also not occur exclusively while some other sleep disorders are occurring such as:
Breathing-Related Disorder, Narcolepsy, Circadian Rhythm Sleep Disorder, or a Parasomnia. Other findings
have also shown substance abuse may occur due to the person trying to self-medicate themselves to help sleep
and fight fatigue. Laboratory findings from sleep labs show sleep stages 3 and 4 are decreased while stage 1 is
increased, therefore sleep is lighter and not as deep or restful. Muscle tension, as well as EEG (certain types of
brain activity) activity, often occurs at this time. Also, Primary Insomnia often occurs abruptly due to some sort
of stressor and may last several years. (DSM IV, 4ed, 1994)
Biomedical treatments for sleeping disorders include various suggestions and medications. Ultimately,
the treatment will depend on the underlying cause or causes of the sleep disorder. Lifestyle changes can often be
the first toward treating a patient. Recommendations may include: a regular sleep schedule and bedtime routine,
an environment should be set up allowing a peaceful sleep, bedding such as pillows and blankets to make body
positioning comfortable, exercise, meditation or different types of relaxation exercises, and avoidance of
commonly used stimulants and diuretics. Stimulants, depressants, and diuretics such as: caffeine, sugar,
nicotine, prescription diuretics, and alcohol should at least be avoided prior to bedtime. Treatments using light
exposure may also be used, this may be due to light’s effect on melatonin. Melatonin is a hormone released at
night by the pineal gland which helps regulate our sleep-wake schedule. Some doctors may even prescribe
melatonin to help a person sleep. (Merck Manual, 17ed, 1999) Regular physical exercise helps the body in
many ways and is conducive to sleeping as found by the Stanford University. (Ohayon, 2004) Other aspects of a
person’s lifestyle may be addressed, such as stressors occurring in a person’s life and how the person can
respond to the stressors in a healthier and less sleep disruptive way. If there is a past or current history of
substance abuse a patient may need to consider treatment for this since it may be continuing the cycle of sleep
disruption as well. (DSM IV, 4ed, 1994)
Biomedicine also has many types of pharmaceutical medications which may be prescribed. These
medications are often referred to as hypnotics, in that they are primarily used to induce sleep. Hypnotics
include: Benzodiazepines, Imidazopyridine, Antidepressants, Antihistamines, and others. These medications
may be used along with others or not at all if the person has problems other than sleep occurring. For example,
if a person is experiencing nocturnal leg cramps quinine sulfate, calcium, or diphenhydramine may be used at
bedtime to help relax the leg muscles and nervous system. Another example would include a person suffering
from insomnia and depression. In this case they may be prescribed sedating tricyclic antidepressants around
bedtime to help both the insomnia and depression. (Merck Manual, 17ed, 1999)
Since hypnotics are commonly prescribed to people suffering sleep disorders it is important to
understand how they are helpful, as well as not so helpful. Safety, including effectiveness, possible addiction,
and side effects, are often researched to alert primary care providers and patients of any serious problems or
positive findings. Unfortunately, all hypnotics include a risk of substance abuse including overdose, addiction,
and withdrawal. Like many other medications, side effects can also occur, including drowsiness, fatigue, slurred
speech, in coordination, problems driving a vehicle or operating machinery, decreased mental alertness, and
even amnesia. Rarely do they cause skin rashes and stomach or other GI problems. Patients are advised to avoid
other CNS (central nervous system) depressants such as alcohol and other prescription medications. Abrupt
termination of the medication can also cause tremors or seizures in the person. Combining certain drugs, like
anticoagulants, with certain hypnotics can also cause negative side effects. (Merck Manual, 17ed, 1999)
Hypnotics are given cautiously to people with certain ailments and the elderly. The elderly, if given
hypnotics, may experience more pronounced side effects including restlessness, dementia, and anxiety. (Merck
Manual, 17ed, 1999) The American Academy of Family Physicians states, for people 65 and older, falls are the
number one accident and main cause of serious injuries and accidental death. Falls can occur due to a loss of
balance related to many reasons, including medication side effects. Falls and impaired memory can be serious
conditions for anyone, but especially elderly persons. (American Family Physician, 2005)
A double-blind, randomized, four-way, cross-over study was done in France using 49 healthy adults
volunteers 65 years or older. Twenty one of the patients were male and 28 were female. People with significant
usage of alcohol, nicotine, and other medications which could interfere with the medications being researched
were excluded from the study. This study, printed in the European Journal of Clinical Pharmacology in
2003, focused on how and if certain prescription hypnotics can be used safely with elderly patients. The
medications were administered at night and included a placebo, Zolpidem 5mg (ambien), Zopiclone 3.75 mg
(Imovane), and Lormetazepam 1 mg. The patients underwent four treatment periods with a one week break
between them. Results were measured up to 10 hours after the medications were taken. Psychomotor tests were
used and these measured body sway, attention changes, reaction time, tracking, and memory and learning
changes. To measure a patient’s subjective sense of sleep, including the ease of getting to sleep, quality of sleep,
ease of wakening, and behavior after wakening, the Leeds sleep evaluation questionnaire was used. Sedation
was also measured using a visual analogue scale. Any negative side effects or problems were also noted during
the study. Results showed all drugs increased body sway and sedation for up to 8 hours after taking the
medication versus the placebo. Zolpidem, however did not cause body sway after 5 hours, while patients on
Zopiclone and Lormetazepine displayed body sway 8 hours after taking the medications. Zolpidem also did not
cause any significant memory effects, while patients displayed delayed reactions and decreased memory recall
when taking Zopiclone or Lormetazepam. The results of this study were in favor of Zolpidem, due to its short
lasting effect on body sway and it did not cause significant memory problems. (Allain, 2003)
Although the study found Zolpidem to be the safest drug out of the three studied, it still had side effects,
including body sway. The Physicians Drug Handbook reports Zolpidem may cause side effects such as:
headaches, abnormal dreams, depression, dizziness, sleep disorder, light-headedness, chest pain, abdominal
pain, vomiting, joint and muscle pain, rashes, and even flu like symptoms. Overdose of Zolpidem can cause
cardiovascular, respiratory, and cognitive changes as well as coma. Zolpidem is passed to breast milk and
should be avoided in pregnant and breastfeeding women. Safety has not been established for geriatric patients.
One other special consideration listed, among others, is Zolpidem should only be taken for 7 to 10 days and
then patient should be re-evaluated, especially if the patient and practitioner want to continue the drug longer
than 2 weeks. (Physicians Drug Handbook, 11ed, 2005)
The costs of these medications and treatments can vary significantly. If a person has insurance they may
be able to purchase medications at a lower price and may have some coverage for counseling and primary care
provider appointments. On the internet Zolpidem cost from $100 to around $200 dollars for a one month or two
month supply. (medsonlinepharmacy.com, 2005) Counseling and primary care provider appointments can range
in price from low income clinics offering free or sliding scale appointments to specialist appointments which
may cost several hundred dollars. If a sleep lab equipment is used the cost can be quite expensive especially if
the patient stays overnight in the lab. It is always important for a person to discuss their health concerns with
their primary care provider, such as a medical doctor or nurse practitioner. However, even if an accurate
diagnosis and treatment is made, sleep problems may continue despite treatment. It is important for people to
know they have many other options besides pharmaceuticals. Lifestyle changes can often be very important,
even in Traditional Chinese Medicine, however many people have a difficult time implementing them and
changes in lifestyle tend to be slow. Other options people should consider if pharmaceuticals are not working
well or they choose not to take pharmaceutical medications include: seeking a practitioner of Traditional
Chinese Medicine, a massage therapist, a naturopath, and counselors such as licensed clinical social workers
and psychologists.
It is evident that although pharmaceuticals, such as the ones mentioned earlier, have helped many
people. They also carry risks of negative side effects occurring, cost a lot of money, and are often used long
term. Many people are seeking new ways to treat their health and sleep problems. The National Institutes of
Health, or NIH, is a governmental organization which has created a center, The National Center for
Complementary and Alternative Medicine, to oversee the safety and effectiveness of complementary practices
in the United States. NIH states that in 2002, a survey of acupuncture use in the U.S. showed 8.2 million people
have used it and 2.1 million people have used in the last year. (National Center for Complementary and
Alternative Medicine, 2005) These numbers continue to grow as more research shows how effective
acupuncture can be for a number of medical problems.
I have discussed the biomedical aspect of sleeping problems, I will now take you on a TCM
journey. Our first stop is a brief history and theory of TCM (Maciocia, 1989., Maciocia, 1994., Liangyue,
1999). I will then discuss the TCM view of sleeping problems, the causes, treatments, and related research.
Traditional Chinese Medicine, or TCM, is a newer name for ancient Chinese practices of healing. TCM
includes acupuncture, herbs, massage, moxa, cupping, gua sha, and some other modalities as treatment methods
for physical, mental, and emotional problems. Acupuncture and Chinese medicine have been practiced for at
least 2500 years in China. The first acupuncture tools were made of stones or bian. Bamboo, wood, and metal
were used as well, but this occurred later in history, around 200 B.C. Stones and other acupuncture tools were
used much differently than the single use, sterilized metal needles commonly used today. In the past the needles
may not have even been used to puncture the skin, unless incising abscesses, draining pus, and letting blood out.
The tools may have been used by the healers or shamans through certain placements and ways of placing them
on the skin. In ancient times there was little or no understanding of our body anatomy and physiology (parts and
functions), as well as germs, so if someone was sick it was often thought to be an evil spirit. The acupuncture
tools and herbs may then have been used to drive out evils or demons from a person.
Traditional Chinese Medicine is a compilation of theories which many believe were becoming well
known schools of thought and medicine around 500 B.C. The different philosophical schools included: yin yang
theory, five element theory, anatomy and physiology, earth element or spleen and stomach, and many others.
Many of these schools passes their knowledge orally to patients and students. However, between 206 B.C. and
A.D. 24, also known as the Western Han Dynasty, the first book on acupuncture, channels, collaterals,
diagnosis, treatment, and some of the different schools of thought was written. Huang Di’s Internal Classic, also
known as, The Yellow Emperor’s Classic, was the first book written on this medicine. Since this time many
books have been written on acupuncture, Chinese medical tools, and herbs. Many books are still needing
translation into English from Chinese, but the amount of books available now to English speaking Chinese
medicine practitioners has largely increased in the last few decades. Traditional Chinese Medicine is a newer
name, stemming from around the 1960’s. During this time China began training more students from other
countries and within China. China needed a way to bring its rich history and varying schools of medicine
together in a practical way so that students both in and out of China could learn the medicine quickly versus
having it taught through families and lineages. To do this they continued to compile much of the schools of
thinking together to create a thorough and detailed diagnostic procedure and treatment protocol for patients.
Included in Traditional Chinese Medicine is yin and yang theory, five elements, zang-fu, and other theories
which every practitioner uses to diagnose and treat their patient. There are other types of acupuncture and
Oriental medicine, such as Japanese acupuncture, Korean acupuncture, French and even Mayan.
I will now talk about some concepts and theories in this medicine which are probably unfamiliar to
many people. Yin and yang, five elements, zang and fu, shen, qi, body fluids, blood, essence or jing, and
meridians are an example of these concepts. These theories are fundamental to understanding the foundation for
Traditional Chinese Medicine. Yin and yang may be the most familiar term to many people. It is a popular
symbol with a circle and two fish like objects, usually black and white with the opposite colored eye inside the
circle. Yin is represented by the black fish and yang by the white fish. Yin and yang are relative terms, meaning
that they always exist together and in relation to each other. For example, yin is thought of as dark, heavy, wet,
female, black, night, and contracting while yang is light, dry, male, white, and daytime. The list can go on and
on, but yin and yang are always relative terms such as a mountain is both yin and yang, the yin side is the side
in the shadow of the mountain while the yang side is in the sun. A woman is more yin compared to a man, but
her head is yang compared to her lower body and her external body and skin is more yang compared to her
internal body and organs. Sleep is yin compared to non-sleep. While we sleep our yang energy, especially our
heart yang energy, moves inward and yin energy enfolds the body. If we are disturbed for some reason before or
during our sleep our yang energy cannot find a place to rest and be calm during the night, thus the yin energy is
unable to enfold the body. In effect, sound sleep does not occur.
The five elements include water, earth, metal, fire, and wood. These elements are seen as naturally
occurring elements in nature. Traditional Chinese Medicine’s roots are with ancient healers who observed the
interactions and similarities between nature and human bodies. We know what water is. H2O can be in an
ocean, lake, and fall as rain. TCM may treat a person for a water problem if their bodily water is not being used
and metabolized right, resulting in a feeling of heaviness, a band like headache, edema or puffiness, and
problems that are worse in damp weather. Another example of how the five elements are used as a diagnostic
and treatment tool are the symptoms and signs of fire in a person. Fire creates heat and things that are dry,
especially wood, can easily catch fire. A bodily heat problem can result in fever, irritability, red face, red
tongue, rapid pulse, constipation, heavy menses, and even hot swollen joints. Fire can also cause sleeping
problems such as in the TCM diagnosis of Liver Fire or Heart Fire.
The five elements are all connected to each other in simple and complex ways. The elements are all
representative of the seasons, tastes, sounds, emotions, organs or channels, colors and many other things. A
common way to describe the cycle begins with the earth element, which often is thought of as the mother or
nourisher. Earth season is late summer, the emotion is worrying, the earth taste is sweet, and the color is yellow.
The earth element relates to the digestive organs spleen and stomach. The next element, metal, arrives due to
the earth providing metal in the ground. Metal represents sadness or grief, the color white, the season of
autumn, the taste of acrid, and its organs are the lung and large intestine. From metal comes water. Water is the
absolute yin, its cold and its season is winter, its emotion is fear, the color is black or dark blue, its taste is salty,
and its organs are the kidney and bladder. Water nourishes wood. Wood burns easily so it can catch fire easily if
overheated. Wood is spring, its emotion is anger, the color is green, the taste is sour, and its organs are the liver
and gallbladder. When wood burns it creates fire. Fire’s emotion is joy, its color is red, the taste is bitter, the
season is summer, and its organs are the heart, small intestine, pericardium, and triple burner. When fire burns it
creates ashes which in turn create the earth. Thus continues the cycle of the five elements earth to metal to water
to wood to fire to earth and again. This cycle allows for the elements to keep each other in balance. If an
imbalance appears in a person, such as fire, then a TCM practitioner knows some likely problems may be not
only in the fire element, but also the wood and water can often be having problems.
Qi, blood and body fluids, shen, and essence are the four treasures. These make up each person’s body.
Health depends on a balanced supply and harmonious movement of all. Qi or ki is very important to TCM. Qi
flows through the meridians or channels in the body. Changes in the flow of qi is what an acupuncturist is
seeking. Qi can be evasive, it can be a very strange term to some people, yet others feel they understand it quite
well. One aspect of qi is that it is our life force, our energy, our movements and life all depend on it. When a
person feels tired a lot, studies or worries a lot, has poor digestion, poor sleep, possibly loose stools, a weak and
thin pulse, and a pale tongue then a TCM practitioner may say they have spleen and stomach qi deficiency. All
the organs have their own type of qi. Each organ’s qi helps the organ carry out its functions. Let’s do some
simple exercises. Bring your palms about 4 inches apart, then at a medium or slow speed move them in small
circles staying 4 inches apart. You may begin to feel like there is a magnet between your hands, we call this qi.
Now stand with your feet shoulders width apart, your knees are slightly bent, and your tailbone tucked under
your body. Let your arms hang by your sides, now bring them palms up and reaching away from your body. Qi
moves up. Now bring your hands palms together, qi contracts. Bring your arms out with palms still facing each
other, qi expands. Bring your hands to chest, qi moves in, then push away with palms facing outward, qi moves
out. Now bring your hands back down, palms facing down, qi moves downward. Then bring your hands apart
and finish, qi disperses. Those with martial arts or tai chi experience may find some similarities with these
movements, since their practices also work with qi.
Blood and body fluids can be similar. They are yin while qi is yang. Blood is nourishing while qi is
moving throughout the body and helping the body perform its energetic functions. Blood and body fluids can
become each other. They help all the organs and the body function by providing nourishment, moistening,
keeping muscles and bones strong, as well as many other things. An example of a blood problem in TCM may
include sharp, stabbing pain, bruising, and swelling from a recent injury to the foot. This would be blood
stagnation. Since qi and blood are interconnected, blood is the mother of Qi and Qi is the commander of blood,
there would likely be Qi stagnation as well. Another example of a blood and body fluid problem is blood and
yin deficiency. This can be common for menopausal women whose temperature varies, has dryness on various
parts of her body, gets dull headaches, palpitations, dreams a lot, sleeps poorly, looks pale, is tired, has a light
irregular period, and feels hot at night, possibly in her palms and chest and soles of her feet.
Essence or jing is closely related to blood and body fluids. Blood can actually become essence. Essence
is a general term that includes post-natal and pre-natal jing. Genetics would be a good example of pre-natal jing.
When a person is born with a problem such as mental retardation or developmental problems we say, in TCM,
they have essence deficiency. Post-natal essence occurs after our birth. TCM believes our spleen and stomach
energy is vital to supplying our body with enough nutrients and water to nourish us in a healthy manner
throughout our lives. Our post-natal essence is similar to digestion and food and water intake. We must have
adequate post-natal essence to live. If a person has developmental delays and poor sleep, we may give a TCM
diagnosis of Kidney Jing or Essence Deficiency.
Shen is housed in the heart. It is specific to the heart and can be thought of as our mind and spirit and
mental activities. Heart blood and heart yin roots the shen or gives it a home to reside in. If blood and yin are
plentiful and the heart is healthy the shen is sound. However, if the heart is agitated or in poor health the shen
will not easily reside in its home of the heart, thus leading to sleeping problems. The health of our Shen is also
related to imbalances in our emotions and zang-fu and anything else that disrupts our overall state of health.
When the weather gets really hot and/or a person feels very irritated they may be unable to sleep soundly partly
due to their shen being disturbed. People who have mental health problems, such as depression, insomnia, and
nightmares (as well as other mental health problems) have some level of shen disturbance.
TCM acupuncture relies on locating acupuncture points both on and off the channels or meridians of the
body. It is believed by TCM practitioners, that thousands of years ago, healers were very aware of their bodies.
For example, they were able to notice changes in their eyes if the touched a point on their ankle. Through such
awareness, maps of the human body were drawn with lines running along the front, back, and sides of the body.
There are even some lines representing lines on the inside of the body. These lines came to be called channels
and meridians. They are areas on the body corresponding to different zang-fu organs and Qi. Qi runs through
the body, but is especially accessible in these meridians at the acupuncture points. As a TCM practitioner, I
believe I am helping a person by changing the way their zang-fu organs, shen, and essence function, and by
changing the way the Qi, blood, and body fluids flows through their body. I and other TCM practitioner often
use acupuncture needles to stimulate meridians and acupuncture points. Two commonly needled points in TCM
for sleeping problems include An Mian, located just behind and below the ear and Heart 7, located below the
wrist on the pinkie finger side. Both of these points help calm shen and regulate sleep.
TCM practitioners rely on finding from a person’s pulse and tongue and overall appearance. We will
feel the pulse on each wrist to help us determine our diagnosis. We are feeling for many things, but in general to
see if a person seems to be excess or deficient of Qi and/or blood in certain organs. We divide the pulse into
three sections and each section represents an organ. We feel the pulse in three levels, superficial, middle, and
deep. These levels represent organs as well as whether the problem is superficial or deep in the body. We feel
the strength, quality, and speed of the pulse to help determine the person’s overall constitution, as well as why
their chief complaint is occurring. We look at a person’s tongue body and coating. These can tell us a lot about
their constitution and chief complaint as well. We look at a person’s appearance and body luster and color. For
example a person with little sleep may have a pale and puffy tongue, thick white coat, weak and thin pulse, and
look pale with little luster. They may even have darkness under their eyes. Often TCM practitioners then ask the
patient specific questions. After putting all this information together we will come up with a syndrome
differentiation and TCM diagnosis. This diagnosis is based on the individual person and not the disease. So if
several people have a biomedical diagnosis of primary insomnia, we may have a different TCM diagnosis and
treatment for each of them. We are taught, however, that certain aspects of a person’s energetic body must be in
harmony to have a good night’s sleep.
As mentioned earlier, it is important for our bodies to allow the heart yang Qi to find a peaceful night’s
rest deep in the body and the yin energy to cover and enfold the body as we sleep. Shen is the spirit of the heart
and resides in the heart. If the heart is disturbed in any way the Shen cannot find its home and thus may cause a
number of problems including sleep disturbances. The mind or shen is not the only spirit involved with sleep. In
TCM each organ has a soul or spirit that helps the organ function, like the Shen of the heart. The Ethereal Soul
or Hun in TCM is the spirit residing in the liver. The Hun helps to regulate sleep as well, especially the length
and quality of sleep. If liver blood or liver yin is deficient, in the diagnosis of Liver Yin Deficiency, the Hun
cannot find its home, just like the shen of the Heart. Therefore without a home the Hun will wander during the
night causing dreams and restless sleeping. If the Hun is at home in a healthy liver then a peaceful sleep is more
likely.
When a patient complains of sleeping problems the shen and possibly the hun are not finding their
homes suitable to reside in. Therefore as TCM practitioners we must find out if external causes are the main
problem. For example we all know that caffeine can often be a culprit in restlessness. Other things to consider
are recent changes in the weather, recent life stressors, body pain or other medical conditions, and the intake of
substances which may be causing the sleeping problems. A lifestyle change or patience may be required for a
person to get quality sleep if any of these externally related factors or stimuli are involved.
If external factors do not seem to be a main component of the sleep disturbance, we look at other
common causes. In TCM these can include: excessive worrying, anxiety, pensiveness, mental overwork, anger,
irregular diet, prolonged illness, too much sexual activity, childbirth, congenital or constitutional weakness of
certain organs, and heat in the body. Many other causes or etiologies exist, but I will only explain some of the
more common ones I listed, such as worrying.
Worrying, anxiety, and pensiveness, especially if done a lot, can injure the spleen, lung, and heart zangfu. When these organs are injured they cannot carry out their functions properly and thus digestion, among other
functions, will be effected causing food stagnation, possibly heat, and/or blood deficiency. Blood is made by the
spleen and carried to the heart. The shen must reside in heart blood and yin. These emotions can also affect the
lungs. The lungs are the container of phlegm while the spleen makes phlegm. The spleen is supposed to
transport and transform water as part of its digestive functions, but if emotions have injured it the ability to do
this is weakened and phlegm accumulates. If phlegm accumulates it can cause coughing, shortness of breath,
and if it gets in the heart it can severely disturb the shen. Worry, anxiety, and pensiveness can also cause heart
fire flaring upward to agitate the mind. Some of the common signs and symptoms caused by worry, anxiety,
pensiveness, and injury to the spleen and heart zang-fu organ can include vivid dreaming, pale face, poor
memory, poor sleep, fatigue, poor digestion, palpitations, dizziness, dull headache, loose stools or constipation,
phlegm, coughing, and feeling warm or cold. A possible diagnosis for sleeping problems with these symptoms
may include Heart and Spleen qi and blood deficiency as well as Phlegm Heat harassing the Mind.
Overworking or over studying, excessive sexual activity, irregular diet, and stress can all weaken the
spleen and heart, as well as the kidney yang, especially the kidney yin. The kidney yin supplies the body with
yin, but especially heart yin. The kidneys are yin in nature while the heart is yang in nature, therefore they
harmonize each other. The kidney yin keeps the heart yang in balance and nourishes the heart yin. If the heart
yin is not nourished by the kidney a type of heat, called yin deficient heart heat occurs. If the heart has heat, the
heat can cause fire thus in turn affecting the kidney yin by burning it up. At this point, kidney yin xu can occur.
Some common symptoms and signs occurring here would include sleep disturbances, low back pain, urinary
problems, dryness, poor memory, constipation, feeling hot, palpitations, ear ringing, and even hot flashes. A
possible diagnosis here includes Disharmony between the Kidney and Heart, Heart Fire, Heart Yin Deficiency,
or Kidney Yin Deficiency.
As mentioned before, common TCM diagnoses for sleeping problems can include: Liver Fire, Heart
Fire, Phlegm Heat harassing the Mind, Heart and Spleen Blood Deficiency, Heart Yin Deficiency, and Heart
and Kidneys not harmonized. Many other TCM diagnoses are possible, but all will take the individual’s
constitution and symptoms and signs into consideration along with the complaint of poor sleep.
So now we know that sleeping problems can be caused many different factors. We also know that both
biomedicine and Traditional Chinese Medicine diagnose and treat sleeping problems in their own way with
some similarities such as changes in lifestyle. I will now discuss some recent research using TCM to treat
sleeping problems. In 2002, a randomized, controlled, and double-blind study was done to assess the relief of 18
menopausal symptoms using acupuncture. One of the major symptoms reported was sleep disturbances. The
study involved 18 women from the New England area. Their mean age was 47.3 years old. They were divided
into an experimental acupuncture group and a comparison acupuncture group. The experimental group received
acupuncture designed specifically for their menopause symptoms, however each person received the same set of
points which included: Bladder 15, 23, 32, Governing Vessel 20, Heart 7, Pericardium 6, Spleen 6, 9, and Liver
3. The women in the comparison groups received a tonifying treatment and each received the same points which
included: Liver 4, Kidney 7, and ear points (liver, lung, kidney, sympathetic, shen men or auricular). All women
were eligible if experiencing hot flashes, yet were excluded if they had used within the last three months or
were using a medical or herbal substance, or if they were also being treated with acupuncture or acupressure.
The study found a decrease in hot flashes as well as decline in sleeping disturbances in the experimental
acupuncture group. Also, one month post treatment the reduction of sleep disturbances became significantly
less. (Cohen, 2003)
Another study, published in 2002, by the Journal of Advanced Nursing, found significant results with
acupoints being massaged to improve the quality of sleep and life in end-stage renal, or kidney, disease patients.
This study was a randomized, controlled, and double blind study. Patients were located in outpatient dialysis
centers in Taipei, Taiwan. 105 patients were selected. They were divided into three groups. The experimental
group received acupressure three times a week for four weeks and usual care, the placebo group received sham
acupressure at locations at least 1cm from a meridian and usual care, and the control group received just the
usual car. The acupoints used in the experimental group included: Heart 7, Kidney 1, and Shen Men in the ear.
The comparison group received acupressure 1cm away from meridians. Different tests were used prior to the
study to get a baseline for each individual and group concerning their sleep and quality of life prior to the
treatments. At the end of the study all three groups showed significant improvements in sleep quality, however
the acupressure experimental group showed significantly greater improvements in sleep quality after the study
was completed. Similar to the last study discussed, this study also showed a gradual increase of sleep quality
over time. (Tsay, 2003)
One last study was done using magnetic pearls on the ears of elderly patients to improve their sleep.
This study was published in 2002 by the American Journal of Chinese Medicine. This study was also a
randomized, controlled, and double blind study. Participants included 120 elders over the age of 60, located in
Hong Kong, and were suffering from sleep disturbances. There sleep efficiency was tested prior to the study to
ensure they were having sleep difficulties. Participants were excluded if they had serious physical and / or
psychological illnesses. They were also asked not to take any sleep medications during the study. Participants
were divided into three groups which included: the control group A who received ear acupressure using the
dried stem of a perennial plant with no known therapeutic effect for sleep, the control group B who received ear
acupressure with a small round seed commonly used for ear acupressure, and experimental group C who
received acupressure using magnetic pearls which were tested to ensure a magnetic field and were the same size
as the small round seeds used in group B. Only the experimental group C had the points pressed, the other group
just had the seed or plant over the point with additional pressure applied. A total of seven ear points were used
on all participants, these points included Shenmen, Heart, Kidney, Liver, Spleen, Occiput, and Subcortex. At
the beginning of the study all participants filled out a sleep questionnaire to give information on all aspects of
their sleep, daily habits, medications, smoking, bedtime snack, as well as some other factors that could interact
with their sleep. The patients sleep activity was recorded by a wrist actigraphy and staff in their elder hostels
kept sleep diaries on each participant’s sleep behavior. This study concluded with significant sleep
improvement as seen by increased sleep quantity and efficiency when compared to the control groups. Magnets
are not commonly used in TCM, however this study shows they may be of value to help sleep. However,
another study would be relevant to see if the seeds, when pressed, help sleep as well. The seeds are a common
treatment in TCM, yet patients are told to press the seeds to help with their treatment. (Suan, 2002)
Besides the acupuncture, acupressure, and ear seeds and magnets, TCM practitioners often
usemedicinal herbs combined into complex formulas. I will not talk about herbs today except to say there are
many herbs useful in helping sleep. Some commonly used herbs include Suan Zao Ren, Yuan Zhi, He Huan
Hua, and many, many others. There is not as much research on TCM herbal formulas for sleep, although these
herbs and formulas have been used for thousands of years with anecdotal reports of very good results.
A visit to a TCM practitioner often includes a detailed intake, the practitioner feeling the pulses and
looking at the patient’s tongue, a discussion about any potential side effects of acupuncture and herbs and
massage, and the treatment. The treatment may consist of needles gently being tapped in on different parts of
the body, and/or acupressure, and/or herbs. Several visits are often recommended, especially for sleep
disturbances. A recommendation of 8-10 treatments, where the patient comes one to two times a week, is
common. If the patient shows any signs of better sleep before the 10th treatment, it may be as long of a process
to help the patient. If little or no changes have occurred prior to the 10th treatment, the process may take longer,
but the patient should not give up. The treatments often build upon themselves with the patient doing better
after more treatments. For sleeping problems, changes in lifestyle are often important as well. Also, once sleep
has significantly improved, it would be wise to continue receiving treatments once or twice a month to maintain
the improvement, at least for awhile.
I hope you have enjoyed this talk on Traditional Chinese Medicine for Sleeping Problems. I also hope
you have a better understanding of how your own body regulates sleep in both a biomedical and TCM way.
Take good care of yourselves. You are the number one influence on your health and your sleep. Please feel free
to ask any questions I have not yet answered. Thank you for attending.
Bibliography:
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memory functions of a single dose of zolpidem 5 mg, zopiclone 3.75 mg, and lormetazepam 1mg in elderly
healthy subjects. A randomized, cross-over, double-blind study versus placebo. European Journal of Clincial
Pharmacology 59, 179-188.
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Appendix:
I.
Suen, L., Wond, T., & Leung, A. (2002). The Effectiveness of Auricular Therapy on Sleep Promotion in
the Elderly. The Journal of Traditional Chinese Medicine an international journal of Comparative
Medicine East and West, 30 (1), 429-447.
1. TCM practitioners were used to give a TCM diagnosis on insomnia prior to therapy. Points were chosen
according to TCM, yet it was unspecified as to who performed the treatment.
2. Exclusion and inclusion/selection criteria were stated. Exclusion criteria included: serious physical and
psychological illnesses, sleep apnea, regular use of hypnotic or psychotropic medication and unwillingness to
discontinue medication, wearing an implanted electrical device, those with a sleep partner, infection or abscess
or absence of external ears. Inclusion criteria included: volunteers, age 60 or above, suffering from sleep
disturbances, and sleep efficiency scores showing clinically impaired sleep.
3. Patients were randomly assigned to two control group and one experimental group and also receiving
treatments on the left or right ear. The process of randomization was not discussed.
4. Demographics were presented concerning the randomization. Drop out rates were 18% in the control groups
and 13% in the experimental group. Specific reasons were listed for each drop out. If dropouts occurred then
participants were replaced until the estimated sample size was reached. All participants were of Chinese origin.
No other specific demographics were given concerning the groups but overall demographics were given such
as: 120 participants, 92% were female and 8% were male, health status was stable, one patient smoked, etc.
5. Rationales were presented for the choice of acupoints and treatment parameters. Ear points were selected
including: Shenmen, Heart, Kidney, Liver, Spleen, Occiput, and Subcortex. Heart was chosen since the mind
resides in the heart and the heart can calm the mind. Kidney was chosen to tonify essence. Liver was chosen to
soothe the liver and regulate the flow of Qi. Spleen was chosen to promote digestion and fluid drainage. Occiput
and Subcortex to calm the mind.
6. The acupressure and treatments were discussed in good enough detail so they could be repeated.
7. Yes, I think so. Wrist actigraphy was used to monitor sleep behaviors and the programs it used were listed,
sleep diaries were used, sleep questionnaires were used initially, ear points were verified with a potentiometer
(electrical detector), baseline data was collected using actigraphic monitoring (specific parameters were listed).
One way analysis of variance (ANOVA) procedures evaluated between group differences and repeated
measures of analysis of variance (RANOVA) further investigated differences.
8. Not stated.
9. Not stated
10. Data taken from actigraphic monitoring and sleep diaries were collected for before and during the period of
therapy and three days post therapy. The total treatment course lasted three weeks. This specific study did not
check on long lasting benefits.
II. Cohen, S., Rousseau, M., & Carey, B. (2003). Can Acupuncture Ease the Symptoms of Menopause? Holistic
Nursing Practices,17 (6), 295-299.
1.Training was not indicated, only information given was the acupuncturist was licensed.
2. Specific inclusion included women were experiencing menopausal hot flushes and who agreed to cease any
previous treatment for these s/sx at least 3 months prior to the study. Exclusion criteria included concurrent
treatment of menopausal s/sx with hormones, medications, herbs, acupuncture, and acupressure.
3. Patients were randomized to either an experimental acupuncture group or comparison acupuncture treatment
group (who received acupuncture for general health rather than menopausal s/sx). The acupuncturist performed
the randomization and set up the appointments for acupuncture treatments. Data was collected in the
acupuncturist’s private office, but participants and principal investigator were blinded to their group
membership.
4. Specific group demographics were given. Eighteen women total participated, 8 in the acupuncture treatment
group and 9 in the comparison group. General demographics included: one participant dropped out, 16 women
were Caucasian, 1 was Hispanic, mean age was 47.3 years, all had hot flushes, and other general demographics
were given.
5. General rationales were given for choice of points, for example women in the experimental group had points
related to menopausal symptoms while the comparison group points were for general tonification. Both were
given daily symptom diaries to record specific information regarding s/sx.
6. The acupuncture points were given as well as needle retention, number of treatments, a treatment course, and
location of treatment setting. However stimulation, type of needle, depth of needle was not given.
7. The clinical endpoints could be more detailed. Data was only taken from the diaries, yet the exact recordings
and measurement techniques in the diaries are unknown.
8. Yes, the principal investigator was blinded.
9. Not stated.
10. Long term follow up data was not presented but the course of the study lasted 12 weeks.
III. Allain, H., Bentue-Ferrer, D., Tarral, A., & Gandon, J. (2003). Effects of Postural oscillation and memory
functions of a single dose of zolpidem 5 mg, zopiclone 3.75 mg, and lormetazepam 1mg in elderly healthy
subjects. A randomized, cross-over, double-blind study versus placebo. European Journal of Clincial
Pharmacology 59, 179-188.
1. Medication was taken with water in the presence of an investigator (whose credentials are not stated)
2. Inclusion criteria included: age of 65 or older, male or female, body mass index below a 20% deviation, and
others. Exclusion criteria included: current treatment that could interfere with study, history of allergies to
medications or current allergies, alcoholism, more than 20 cigarettes a day, and others.
3. Yes, this was a double-blind, randomized, single dose, four-way, cross-over study. Design was a balanced
latin-square design, otherwise randomization process not stated. Subject acted as their own control for the
duration of the study.
4. Maybe? The general demographics included 49 patients, 21 males, 28 females, one subject withdrew for
health reasons. I cannot find specific group demographics but I wonder if the balanced latin-square design may
mean that all the subjects were given all the medications, but just at different times?
5. Yes, rationales were presented regarding choice of medications. They chose popular medications to see
which ones cause more negative side effects.
6. No, I am not sure how people were randomized and how they were represented demographically in each
group. Yet the type of medication, dose, administration, treatment procedures is easily followed.
7. Yes, Assessments were given in great detail, these included: body sway, Leeds sleep evaluation
questionnaire, LMT learning memory task, and other tests to assess how the medications affected the
participant. Statistical analysis was described in detail and software used was listed.
8. Not stated, but assumed so since it is termed a double blind study.
9. Not stated.
10. Not stated, especially since this looked at effects of medications on elderly within hours of taking the drug.