Chapter contents

INTRODUCTION

Sleep disturbances are very common in Western patients; when asking a patient about a sleep problem, it is important to clarify whether there is difficulty in falling or staying asleep, waking up early in the morning or excessive dreaming.

WHY WE ASK

It is essential to ask every patient about their sleep because this gives an indication of the state of the Mind (Shen) and Ethereal Soul (Hun). A disturbance of the Mind or Ethereal Soul, or both, is of course extremely common in Western patients whose lives are generally subject to a considerable amount of stress.

The length of sleep needed varies according to age and, in general, it gradually decreases in one’s lifetime, being highest in babies and lowest in the elderly. We should therefore take age into account when judging whether the patient’s sleep is adequate or not.

WHEN WE ASK

I ask about sleep and dreaming early on in the consultation in every case. Even if a patient does not apparently present with any problems of that kind, I always ask about sleep and dreaming to get an idea of the state of the Mind and Ethereal Soul.

HOW WE ASK

It is important to be specific when asking about sleep and dreaming; it will not suffice to ask ‘Do you sleep well?’ I generally ask patients whether they fall asleep easily, whether they wake up during the night and whether they dream excessively. The last symptom is difficult to define as we all dream: dreaming seems to be an essential part of sleep, performing a function that is still the subject of debate and disagreement. What, therefore, constitutes ‘excessive’ dreaming in Chinese medicine? I personally think this can be defined either as having many dreams, to the point of feeling exhausted in the morning because of them, or as having unpleasant dreams which leave one tired and slightly disturbed in the morning or even wake one up during the night.

If the patient dreams excessively, I then ask whether there is any recurrent dream. Apart from a modern psychological interpretation of dreams according to the theories of Freud, Jung and others, I always try to interpret recurrent dreams in terms of Chinese medicine. The ‘Simple Questions’ has a long list of dreams with their significance in Chinese medicine and these are listed in Part 5, Chapter 81. For example, recurrent dreams of water usually indicate a Kidney deficiency (while in Jungian psychology water is a symbol of the unconscious).

INSOMNIA

Symptoms and Signs, Chapter 81

In general, sleep depends on the state of Blood and Yin, especially of the Heart and Liver, although the Blood and Yin of other organs also influences sleep. During the night Yin energy predominates and the Mind and the Ethereal Soul should be anchored in the Heart-Blood and Liver-Blood respectively (Fig 40.1).

A sleep disturbance may be due to the Mind or the Ethereal Soul not being anchored in the Heart-Blood(or Heart-Yin) or the Liver-Blood (or Liver-Yin) respectively; this can happen either because there is not enough Blood or Yin to anchor the Mind or the Ethereal Soul, or both, or because a pathogenic factor (such as Heat) agitates them. The former is an Empty type of sleep disturbance, the latter a Full type. In both cases, the Mind or the Ethereal Soul is said to ‘float’ at night causing insomnia (Fig 40.2).

In general, in Deficiency, a difficulty in falling asleep indicates a Blood deficiency of the Heart, Spleen or Liver, whereas difficulty in staying asleep and a tendency to wake up during the night indicate a Yin deficiency. Of course, waking up during the night may also be due to a Full condition such as Heat, Fire, Phlegm-Fire or retention of food.

When diagnosing sleep disturbances it is important to distinguish, first, a Full from an Empty condition and, secondly, a Heart from a Liver pattern. Full conditions are characterized by very restless sleep with a feeling of heat, agitation and excessive dreaming; Empty conditions are characterized by not being able to fall or stay asleep without any of the above symptoms. A Liver pattern causing insomnia is characterized by excessive dreaming and, compared with a Heart pattern, a more severe restlessness.

However, the Heart and Liver are not the only organs that may cause insomnia: the Stomach, Spleen, Kidneys and Gall-Bladder may all play a role in insomnia. For example, a deficiency of Spleen-Blood often accompanies a deficiency of Heart-Blood and contributes to causing insomnia (the famous formula Gui Pi Tang Tonifying the Spleen Decoction treats insomnia from these patterns). Kidney-Yin, like Liver-Yin, also needs to anchor the Mind and the Ethereal Soul at night; therefore a deficiency of Kidney-Yin, with or without Empty-Heat, is also a frequent cause of insomnia.

A deficiency of the Gall-Bladder may cause someone to wake up early in the morning without being able to fall asleep again.

A less common cause of insomnia is residual Heat in the diaphragm, which may occur after an invasion of Wind-Heat; this is obviously an acute type of insomnia with recent onset.

For a detailed description of the patterns causing insomnia see Part 5, Chapter 81. Figure 40.3 illustrates the aetiology and pathology of insomnia differentiated into the main Empty and Full patterns.

The main patterns appearing in insomnia are summarized in Box 40.1.

EXCESSIVE DREAMING

Symptoms and Signs, Chapter 81

Excessive dreaming is another common sleep disturbance, which is usually due to a pathogenic factor agitating the Ethereal Soul; this may be either a pathogenic factor such as Fire or Phlegm-Fire, or such a one as Empty-Heat deriving from Yin deficiency.

‘Excessive dreaming’ is difficult to define because dreaming is a normal, physiological aspect of sleep. From the perspective of Chinese medicine it can be defined as a level of dreaming, whether pleasant or unpleasant, that makes the sleeper restless or wakes the patient up; it also includes nightmares, especially when they are recurrent. Other doctors define ‘excessive dreaming’ as waking up with an unpleasant feeling from dreaming; by implication, from a Chinese perspective, ‘normal’ dreaming is not remembered in the morning.

‘Excessive dreaming’ was called Ye You, which means ‘wandering at night’, or Meng You, which means ‘wandering in one’s dream’, or Meng Xing, which means ‘moving in one’s dream’: all these terms are a clear reference to the wandering of the Ethereal Soul at night when we dream too much.

With the exception of Heart and Gall-Bladder deficiency, excessive dreaming is usually caused by a Full condition, generally of the Liver or Heart, such as Liver-Fire, Heart-Fire or Phlegm-Fire in the Heart. Full conditions of the Stomach also frequently cause excessive dreaming, especially Phlegm-Fire in the Stomach and retention of food.

The main patterns causing excessive dreaming are summarized in Box 40.2.

SOMNOLENCE

Interrogation, Chapter 44; Symptoms and Signs, Chapter 81.

Somnolence means dozing off frequently in the daytime or early evening. Some Chinese books also add that the patient wakes up as he or she breathes out and then dozes off again. ‘Somnolence’ also includes some people’s physiological need of sleeping a longer time than normal, which, in adults, is approximately 7–8 hours.

Somnolence may be due to Deficiency, usually of Qi or Yang, or both, or to Excess, such as Dampness or Phlegm. The most common situation is a combination of Deficiency (of the Spleen or Kidneys, or both) and a Full condition consisting of Dampness or Phlegm.

Of course, when a patient complains of somnolence, one should first of all enquire about the patient’s working hours: if the person works very long hours (a very common occurrence in Western industrializedsocieties) then somnolence is not a pathological symptom.

For a detailed description of the patterns causing somnolence, see Part 5, Chapter 81.

Box 40.3 summarizes the patterns underlying somnolence.