by Dr. Sydney Malawer, DAIM L.Ac.

Insomnia is a common issue brought up in our clinic. Whether it's a short bout or a long struggle, insomnia affects almost everyone at some point in their lives. The past few months our patients have been presenting with some extremely complex insomnia cases in the clinic. Some have been super responsive to treatment while others have been more resistant, and when we're faced with a clinical challenge we always go back to basics through the teachers of great masters and thought leaders of East-Asian Medicine. The first stop is almost always the books and lecture notes of Ikeda sensei, and I've found his take extremely eye-opening and compelling this time around so we wanted to share some of his perspective here.

The Process of Sleep in East-Asian Physiology

The process of sleep is dependent on the circulation of yang qi and blood, so a disturbance in that circulation will cause a sleep disturbance whether that be insomnia or hypersomnlence (aka super sleepiness). Yang qi is generated by the Spleen/Stomach and is circulated throughout the body via Lung qi. During the day, yang qi circulates through the yang areas (head exterior) and helps with the function of the sensory organs. At night yang qi goes to the yin areas (interior), which will lead to sleep. Blood also circulates with yang qi during the day, and at night it returns to the Liver where it is restored and renewed. 

Insomnia occurs when the generation and/or circulation of yang qi and blood is disrupted. If the yang qi doesn't go into the yin areas at night or the blood doesn't return to the Liver, the result is insomnia. 

Types of Insomnia

Ikeda sensei says that although there are different origins of insomnia, there is a common pulse pattern - the right proximal (PC/SJ/Kd Yang) will be stronger than usual and the overall pulse will be rapid and that if it is not rapid it is likely that there is no insomnia but rather the person is waking up not feeling rested. He goes on to differentiate the different types of insomnia by how they manifest, summarized below:

• Difficulty falling asleep: The archetype for this pattern is usually "tired but wired" - meaning they have low grade fatigue during the day and then when bedtime comes they can't seem to wind down. According to Ikeda sensei this type is usually a result of Spleen deficiency where yang qi gets trapped in the yangming channels on the head and therefore doesn't go inward at night. It is typical for people with this type of insomnia to feel sleep after meals. 
• Waking during the night or waking early: The archetype for this pattern is someone who considers themselves a light sleeper, usually wakes once or twice in the middle of the night either to pee or with low-grade anxiety and a little bit of sweat, or wakes up bright eyed and bushy tailed at like 4am regardless of when they went to bed. This type is usually due to a yin deficiency with deficiency heat in the Heart or Lungs, such as in Liver deficiency yin deficiency or Kidney deficiency yin deficiency. At night when the yang qi enters the yin areas it combines with this deficiency heat, causing heat to rise to the head and wake the person up. 
• Inability to sleep at all: The archetype for this pattern is someone who gets into bed and just can't turn their brain off. This is a situation that involves more blood than yang qi as there is "simply not enough blood and so it is unable to return to the Liver." (p. 249) This presents as either a Liver deficiency yin deficiency or Liver deficiency yang deficiency pattern. People with this pattern will suffer for sleeplessness more often when they exercise or think too much. (Sounds like so many of us, no?!)
• Excessive dreaming and/or not feeling rested upon waking: The archetype for this pattern is our typical type A personality who drinks at least 3 cups of coffee everyday and works all the time. Since Ikeda sensei's analysis here is absolutely fascinating I'm going to quote it directly because summarizing it doesn't do it justice: "This is often seen in people with constitutional Liver deficiency who tend to have long, narrow eyes or small eyes. In addition, their ears are folded sharply at the first fold - the antihelix - and when viewed from behind, this fold juts out beyond the helix. They are usually very positive about their work, requiring that it be done systematically and exhaustively; otherwise, they are dissatisfied and can become irritable. Their brain may also be whirring away 24 hours a day, and they therefore find it difficult to relax. This background makes them prone to insomnia. When this constitutional tendency becomes pathological, they have many dreams and do not feel rested after sleeping. If they continue to exert themselves, their blood deficiency can worsen to the point where they become unable to sleep whatsoever. When this happens, the sides of the rib cage are cold because their Gallbladder qi is not being circulated." (p.250)

Acupuncture for Insomnia

First and foremost, you always treat the root deficiency. For example, if there is a Spleen deficiency you treat either P7/Sp3, P6/Sp4, or P8/Sp2 depending on the amount of deficient heat present. (For more information on Ikeda sensei's approach to root treatments, I highly encourage you to check out the book). Many times just treating the root can resolve the problem in a few short treatments. If this is a chronic issue or one exacerbated by life circumstances, it is likely to take anywhere from 5 to 20 treatments before the issue is largely resolved. Below are some of the strategies Ikeda sensei proposes for addressing insomnia:

• retain needles at UB2, GB4, and hard spots on the abdomen as well as against the channel on the Gallbladder meridian on the legs (GB38 or GB41)
• contact needling on the temples (taiyang)
• on the upper back, needle or use chinetskyu moxibustion on the painful spots between Du9 and Du12 while also retaining needles at UB13, UB15, and hard points between the scapulae.
• tonetskyu moxibustion at Kd1 or Shimian

Herbal Medicine for Insomnia

This section isn't taken directly from any chapter of Ikeda sensei's book but rather from multiple sources of Ikeda sensei's teachings (books and lectures mainly). Below is a list of the a few of the main classical formulas used for insomnia and which patterns they address:

• Suan Zao Ren Tang: For trouble falling and/or staying asleep due to Liver (blood) deficiency. In some cases can be used for inabilty to sleep at all. 
• Chai Hu Jia Long Gu Mu Li Tang: For waking during the night due to Kidney deficiency with Liver excess/qi stagnation. (Personally this one is my favorite because it matches my pattern tendency - it's like taking a literal chill pill!)
• Wen Dan Tang: For taking early and unable to fall back asleep due to Spleen deficiency.
• Chai Hu Shu Gan Tang: For any insomnia case characterized by Kidney deficiency and Liver excess/blood stagnation. It is usually accompanied by rib-side and/or chest discomfort.
• Huang Lian Jie Du Tang: For inability to sleep due to heat in the chest - usually due to Spleen deficiency but can be combined with another simple formulas for Kidney or Liver deficiency as well. 
• Jia Wei Xiao Yao San: For inability to sleep at all due to Liver deficiency (blood deficiency). This is particularly useful for pre-menstrual insomnia that occurs the day or two before bleed. 

I hope Ikeda sensei's perspective has given you context to your own condition or something to chew on for future treatments. To learn more about our approach to insomnia, visit the Internal Medicine page. If you have questions about how East-Asian medicine can help you, schedule a free phone consultation here.