Melody's Musings

Insomnia is a sleep disorder most everyone has heard of as it is extremely prevalent.  Understandably, both “Western Medicine” and Traditional Chinese Medicine (hereafter abbreviated TCM) have rationales and treatment plans for insomnia.  Many randomized control trials and systematic reviews have been performed from both perspectives.  This blog post will examine the management of insomnia from both medical perspectives as well as current research regarding treatment outcomes using acupuncture for the condition of insomnia.

The Medical Management of Insomnia:

Insomnia is a chronic sleep disorder which has its own classification in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). Commonly known to most as a condition involving difficulty sleeping, it also includes difficulty maintaining sleep. “Chronic insomnia is defined as difficulties falling asleep, maintaining sleep, and/or early morning awakening occurring at least three times per week over three months plus at least one related daytime impairment (fatigue, attention impairment, mood disturbance, impaired performance)” (O’brien & Weber, 2016).

As can be expected, this can lead to disruption of lives for those suffering from the condition. Insomnia can cause one to feel tired the next day as they’ve experienced reduced sleep. This can also result in problems such as difficulty concentrating, “Mood disturbances and cognitive difficulties”, decreased quality of life, and other comorbid conditions “that include but are not limited to disorders of pulmonary, cardiac, rheumatologic, neurological, endocrine (such as thyroid), and gastrointestinal systems” (Schutte-Rodin, et al., 2016).

There are a number of treatment options available to those with insomnia. Many simply resort to a number of available over the counter options before seeking out medical help for the condition. Some of the over the counter options include things like taking antihistamines, melatonin or valerian root. These over the counter options are considered by most professionals to be temporary aides and not for long term use as they do have a number of potential side effects, such as lingering drowsiness or foggy headedness the day following their use. 

Once an individual seeks out treatment from the medical community, “treatment includes cognitive–behavioral therapy (first-line therapy and found to be more effective than drugs in long-term treatment of insomnia) and the prescribing of benzodiazepines and benzodiazepine-receptor agonists. These drugs are unsuccessful in achieving sustained remission in a significant proportion of patients and are associated with serious side effects and dependency. Antihistamines and tricyclic antidepressants, which work by blocking the wake-promoting aminergic and cholinergic transmission, also have serious side effects. The drug Suvorexant, an orexin receptor antagonist, suppresses the wake stimulatory network of sleep–wake regulation. Novel therapies currently being investigated include transcranial magnetic and electrical brain stimulation.” (O’brien & Weber, 2016)

From a biomedicine point of view, “relevant meta-analyses and concluded that CBTi [Cognitive Behavioral Therapy] should be the first line therapy offered to patients (30,31)... Typically therapy includes a combination of: psychoeducation about sleep and sleep hygiene, sleep restriction therapy, stimulus control therapy and cognitive therapy to decrease rumination about sleep as well as relaxation training” (Anderson, 2018). Given these guidelines, it is easy to see how acupuncture may be a helpful adjunctive therapy to the current standards of care. Patients could utilize acupuncture with other therapies to get more immediate relief while awaiting relief from therapies such as cognitive behavioral therapy. 

The Chinese Medical Management of Insomnia:

From a “Traditional Chinese Medicine” standpoint, insomnia is typically “associated with instability or agitation of the shen. This can occur because: the shen is not adequately anchored and secured due to a deficiency of blood or yin, overstimulation and agitation by Heat prevent the shen from settling quietly when the time comes for sleep, or the shen is ‘locked in’ and agitated by constraint from qi and/or blood stagnation” (Maclean & Lyttleton, 2008). The shen, from the TCM point of view is the spirit mind of the Heart. As such, “in practical terms, the shen is most closely associated with our conscious awareness, and is essentially our ability to perceive, interact and communicate with our world clearly. In addition, the shen and the Heart share an intimate and interdependent relationship (TCM describes the Heart as the residence of the shen)” (Maclean & Lyttleton, 2008).

There are a number of different Chinese Medicine patterns which can contribute to the presentation of insomnia. Maclean & Lyttleton list the following potential diagnoses: liver qi stagnation, stagnant heat, liver fire, heart fire, stomach disharmony, phlegm heat, heart blood and spleen qi deficiency, heart and kidney yin deficiency, liver yin and blood deficiency, heart and gallbladder deficiency, and blood stagnation. According to Chinese Acupuncture and Moxibustion (CAM), the potential patterns for insomnia are: deficiency of both the heart and spleen qi, disharmony between the heart and kidney, upward disturbance of liver fire, and dysfunction of stomach. All of these patterns can be separated into two categories: excess and deficiency. 

“The deficiency patterns are mostly due to the shen not being anchored by Heart yin or Blood, so it simply ‘floats away’, or is dissipated instead of resting in the Heart. These patterns usually manifest with symptoms like insomnia, dream disturbed sleep, anxiety with palpitations, phobias and disorientation. Excess patterns are mostly associated with Heat and Phlegm. The Heat can directly affect the Heart (as in Heart Fire) and be more systemic (as in Heat in the blood). Either way, the shen is continually agitated by the presence of the Heat, and restlessness, agitation, and delusional or manic behavior result” (Maclean & Lyttleton, 2008). 

“The excess varieties tend to be more difficult to treat than the deficient varieties, as in excess patterns there are often complicating lifestyle features- like unhappiness or stress at home or at work and habitual mental emotional responses that have to be dealt with for a satisfactory result. The deficiency patterns generally respond quite well to treatment, although herbal and/or acupuncture treatment may need to be combined with an appropriate nourishing diet” (Maclean & Lyttleton, 2008).

The differences required in approach can be problematic when selecting points to be used in Randomized Control Trials for the treatment of insomnia. When approaching this issue clinically, the acupuncturist would first assess the TCM pattern behind the disorder and then “prescribe” points based upon this determination. The points recommended vary depending on the diagnosis. Maclean and Lyttleton does list some points which could be used for insomnia that are not specific to the pattern differentiation, however.  Pattern differentiation is important to me as a practitioner because this is how we tailor points to the individual patient and potentially maximize the effect of the acupuncture treatment.

Discussion:

“The neurological basis for relationships between organ systems, in the biomedical sense, lends some support to the interdependent relationships between the Zang-Fu organs, as espoused in CM theory. Research into heart and heart coherence suggests that the heart behaves like a brain” (O’brien & Weber, 2016). This evidence suggests that TCM theory, which has been in use for over 2000 years has been correct in recognizing the relationship between the heart and brain functions. 

“In the treatment of insomnia with CM, addressing the imbalance associated with the Heart is a key strategy, and there is scientific evidence that indicates that acupuncture, for example, is able to effect physiological changes on the heart that are involved in the pathophysiology of insomnia from a Western scientific perspective… Although this traditional concept appears at first examination incoherent by modern physiological understandings, it does make sense when viewed within the function of the vagal nervous system. The vagus nerve (10th cranial nerve) is predominantly afferent, informing the brain of visceral experience” (O’brien & Weber, 2016).

It is this link to the vagus nerve which is most promising with regard to the effect of acupuncture on insomnia.  The vagus nerve is a cranial nerve which has many connections to the visceral organs of the body and is independent of the spinal cord.  The vagus nerve is well known for its ability to help regulate functions such as heart rate and breathing.  Heart rate is particularly interesting with regard to acupuncture and its effect on insomnia given the close relationship to cardiovascular activity and sleep. 

Conclusion:

 “The pathogenesis of insomnia from a Western biomedical perspective is complex, and involves hyperarousal in both the CNS and ANS. The heart is involved, with changes to HRV [Heart Rate Variability] and heart rate, and there is evidence of a relationship between insomnia, anxiety, and depression in the Western medical literature. The vagus nerve plays an important part in communication between the brain and other systems, including the heart, and may play a role in insomnia. In CM, the Heart, where consciousness is seen to reside, is involved in the pathogenesis of insomnia as well as anxiety and depression, and the interdependent relationships between the organ systems explains this association. There is evidence that acupuncture is able to effect physiological changes in the treatment of insomnia via its impact on the Heart and the heart. Despite apparent differences in how the body is understood, there appear to be some points of intersection between the two medical systems” (O’brien & Weber, 2016). 

As previously discussed, several review articles have found that the body of research suggests that the mechanism of acupuncture is through some combination of effect on endorphin release, micro-injury, and a change in neurotransmitters dopamine and serotonin among others.  “Acupuncture is able to affect the vagal activity and autonomic functions of the cardiovascular, respiratory, and gastrointestinal systems” (O’brien & Weber, 2016).  It is this link between the ability of acupuncture to affect vagus nerve activities and the cardiovascular system which makes acupuncture particularly effective in treating insomnia- on a consistent basis. 

This blog has only explored a small sampling of the available research for the efficacy of acupuncture on insomnia and still found that acupuncture is consistently effective in treating insomnia.  More research would need to be done in order to make any conclusive statements to this effect, however the body of research currently available is suggestive that the effect of acupuncture on the vagus nerve may be the mechanism for acupuncture’s effect on insomnia.

References:

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