Sleep Disturbance
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Sleep Disturbance

Differentiating sleep disturbance is an art in Chinese medicine, and a science in Western medicine. In Chinese medicine, sleep disturbances are categorized as:

  • difficulty or inability to fall asleep
  • difficulty staying asleep
  • waking early or at a particular time during the night
  • difficulty falling back to sleep after waking
  • restless sleep 
  • etc.  

Sometimes people just have a feeling that something is wrong with their sleep, but do not know quite what it is and can not describe it well. The important thing is that they do not waken in the morning feeling refreshed. Other signs and symptoms assists the practitioner in making diagnose, as to the cause of sleep disturbances:

  • Hyperactive Liver yang
  • Heart Fire
  • Heart Spleen, Heart/ Kidney, or Heart/Gallbladder disharmony
  • phlegm mists
  • etc.

There is one pattern of sleep disturbance called Dream-Disturbed-Sleep (DDS) which is unusual because people really do not complain when they dream. I never seen a definitive Chinese medicine definition of DDS. It is mainly described as being woken-up by disturbing dreams (nightmares), or vivid uncomfortable dreaming. A TCM zang fu diagnosis for DDS is Heart/ Kidney disharmony; Heart Heat consuming Kidney Yin. DDS is a term used in both Eastern and Western medicine to describe a certain type of sleep disturbance. Western anatomy of the "Sleep Cycle" shnes more light on the ancient Chinese medicine concept of DDS.

DDS in the WEST
In Western Medicine, DDS interrupts a normal sleep cycle. The dreaming phase is the last phase of a complete sleep cycle, followed by a brief period of rousing to a light sleep state before starting another cycle. Each phase of the sleep cycle is characterized by a brain wave pattern that is essential for the repair & rejuvenation (R&R) of either the body physical or the body psychological. It was discovered that the brain (the body psychological) is detoxifying & repairing during the dreaming phase. But the other phases are as important for the R&R of the body physical. Thus, a person will not experience quality sleep if they dream too much or dream too little. DDS is the result of over-activity in the cerebral cortex.

The brain wave patterns and the subsequent phases of sleep can be monitored in a clinical sleep study setting. A "normal " pattern is several sleep cycles per night. If a person has too many dreams, or is constantly awoken by snoring and/or periods of apnea; or doesn't get enough hours of sleep they will have completed less deep sleep cycles.  Sometimes it is more important to achieve one good deep sleep state, irregardless of how many cycles. In other words, one good deep short nap is as refreshing as a whole night's worth of poor quality sleep. 

Snoring and sleep apnea can interrupt an otherwise normal  sleep cycle. A person can be woken by the sound of their own snoring. And snoring can itself be a sign of sleep apnea, which can also wake one up from deep sleep. A person my not even know they are snoring, or have sleep apnea unless they are observed by another person (or diagnosed in a sleep study lab). Snoring and sleep apnea are caused by some type of obstruction in the upper airway. This obstruction can be caused by the flaccid relaxation of the muscles in the larynx during very deep sleep; compression from being over weight; a structural anomaly in the upper airway; or a combination of these. In Chinese medicine it is due to phlegm (which is symbolic or literal).

Treating Sleep Disturbances
Western medicine can't really differentiate between  the various types of sleep disturbance per sea, unless a person is observed sleeping in a clinical sleep lab setting. This involves being hooked up to EEG electrodes and an apnea monitor. Without diagnostic testing, sleep hygiene is first-line treatment; relaxation techniques, room temperature adjustments, aromatherapy, warm milk etc. Followed by pharmaceutical drugs if ineffective. Hypnotics, Benzodiazapines, muscle relaxants, tricyclic antidepressants, etc. influence different phases of the sleep cycle. This is why if a person is non responsive to one drug, they may be responsive to another. The drawback is that a person can develop dependency upon sleep medication, without ever getting to the root of the problem.

Dependency upon Benzodiazapines (e.g. Ambien) for sleep is common. This is because they are effective, but change neurochemistry very quickly (within 7 weeks of use). If a person has been taking a Benzodiazapine, chronically for years (as many people have) it is difficult, even contraindicated to stop using them abruptly. This can cause a spectrum of withdrawal symptoms. Dependency on Benzodiazapines can be (and in some cases should be) treated with an in-patient or out-patient drug addiction protocol. Western medicine considers the particular signs and symptoms that occur when withdrawing from a particular drug of abuse (DOA). 

TCM also consider the patterns of disharmony that occur when withdrawing from a particular DOA. With Benzodiazapines, Heart Fire may present first. This is when a person needs Benzodiazapines as self-medication to offset Liver Qi Stagnation (LVQS) or central nervous system irritability. Benzodiazapines have an abrupt fluctuation between Heart Fire and LVQS, which is a complex imbalance between the sympathetic nervous system/SNS (excitatory) and parasympathetic nervous system/PSNS (calming). In short, Benzodiazapines cause a down-regulation in GABA & GABA receptors (calming). While the production of endogenous epinephrine/ norepinephrine and their receptors is up-regulated (excitatory). This is the body's way of preventing over sedation from Benzodiazapines. But in the absence of Benzodiazepines, the excitatory part of the CNS now dominates, causing many signs & symptoms of SNS hyperactivity (irritability, anxiety, tachycardia, hypertension etc.). 

How are DDS, snoring & sleep apnea diagnosed and treated in TCM? The auricle (ear) is a good place to start because the diagnostic points are also the treatment points:

  • For snoring and sleep apnea - inspect & test the Mouth, Throat, Trachea & Larynx points. 
  • Heart point (and Neurasthenia area & point) are diagnostic of DDS. Heart point is important because sleep apnea is a risk factor for cardiovascular disease. Heart point will appear atrophied & wrinkled.
  • Neurasthenia area & point are used for all types of sleep disturbances. They will appear with a soft irregular protrusion. There will be a hard protrusion for actual neurasthenia, which is also associated with sleep disturbance. A positive hyperactive electrical-resistance response at Neurasthenia, generally means a person has difficulty falling or staying asleep. 
  • Nervous Subcortex controls a variety of neurological and activities. 

There are many supplemental points depending on the pattern of disharmony. For example, according to 10-Stem theory, the Large/Small Intestines could be the focus of treatment if a person has Phlegm-fire/ Phlegm Misting the Herat/Mind. Sometimes the time one awakens determines what needs to be treated. For example waking in the middle of the night around 1 to 3 a.m. reflects a Liver/Gallbladder type of disharmony.

INTEGRATIVE MEDICINE TIP: The Chinese formulas Tian Wan Bu Xin Dan stands out to minimize the withdrawal signs & symptoms (including rebound insomnia) when a person is weaning off Benzodiazapines. It is a classical formula indicated for insomnia due to Heart & Kidney disharmony. It cools the blood, nourishes the Heart yin, settles the Heart, and calms the shen. It is indicated for insomnia with irritability, restlessness, palpitations, anxiety, and vivid uncomfortable dreaming. The diagnostic key finding for this formula may be soreness of (or actual sores on) the tongue, or tip of the tongue (Heart Fire). Dosing of this formula in a patent (pill) form can be increased from 8 pills 3 times per day to 12 pills 3 times per day as needed (Fratkin, 2001).

References
Fratkin, Jake. (2001). Chinese herbal patent medicines: The clinical desk reference. Boulder, CO: Shyla Publications.














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