Insomnia – “Let’s sleep on it”
- Methods of Review
A comprehensive literature search was performed, first using the words ‘insomnia’, and ‘acupuncture’ then narrowing those searches to include primary, chronic, Alzheimer’s, Parkinson’s, traditional Chinese medicine, pharmacology, cognitive function, auricular and therapies to identify relevant data, clinical studies and case reports published between April 1980 to May 2007. The Cochrane Database of Systematic Reviews (CDSR) (first quarter 2007), ACP Journal Club (1991- April 2007), Database of Abstracts of Reviews of Effectiveness (DARE) (second quarter 2007), Cochrane Central Register of Controlled trials (CCTR) (second quarter 2007), Medline (1950-April 2007), Allied and Complementary Medicine (AMED) via Ovid (from 1985 to April 2007) and CINAHL (Nursing and Allied Health) (from 1982 to 10 May 2007) were searched.
The inability to sleep or poor sleep quality can have serious effects on a persons daily functioning. Insomnia can be caused by an array of physiological, psychological, environmental or behavioural factors. Insomnia can adversely affect a persons day-to-day life by causing fatigue, loss of concentration and mood disturbances, all of which impair their quality of life. People suffering from insomnia either find difficulty initiating or maintaining sleep. Western treatments for insomnia involve behavioural, pharmacological and alternative therapies whilst Traditional Chinese medicine involves the use of both acupuncture and herbal medicine.
- Literature Review
3.1 Western Perspective
According to the International Classification of Sleep Disorders (2001), insomnia is defined as difficulty in initiating or maintaining sleep and is associated with feelings of restlessness, irritability, anxiety, daytime fatigue and tiredness. Insomnia is the most common sleep disorder and can either be a temporary or long-term problem (Shneerson, 2005). There are three types of insomnia including transient insomnia, cyclical insomnia and chronic insomnia.
Transient insomnia is common and usually lasts for approximately three weeks (Shneerson, 2005). It can only be diagnosed after it has been relieved and can be due to changes in sleep environment, high arousal states due to emotional events (for example, an upcoming examination), poor sleep hygiene (for example consumption of stimulants before bed) or short-term circadian rhythm disorders (for example jet lag) (Shneerson, 2005).
Cyclical insomnia is due to an unstable balance between the sleep and wake drives which may be temporary or lifelong (Shneerson, 2005). This may happen when physiological (for example circadian rhythm disorders), psychological (for example anorexia nervosa) or behavioural (for example binge drinking) changes occur (Shneerson, 2005).
Chronic insomnia falls into two main groups, namely, primary insomnia and secondary insomnia. The pathogenesis of primary insomnia is unknown however studies have shown that patients with primary insomnia are in a physiological state of hyperarousal (Saper, Scammel, & Lu, 2005; Stepanski, Zorick, Roehrs, Young, & Roth, 1988). Smith and colleagues (2002) also suggested that primary insomnia is due to abnormal central nervous system activity.
Secondary insomnia can be due to substance abuse, poor sleep hygiene or neurological, medical or psychiatric conditions (Culebras, 2007). The neurological diseases associated with chronic insomnia can be categorised according to degenerative diseases or movement diseases. Studies have shown that patients suffering from degenerative diseases, for instance Alzheimer’s and Parkinson’s disease, or movement diseases, such as restless legs syndrome or propriospinal myoclonus, suffer with insomnia because of either the side effects of the medication or the motor impairment of the disease (Dowling et al., 2005; McCurry, Logsdon, Vitiello, & Teri, 2004; Milligan & Chesson, 2002; Montagna, Provini, Plazzi, Liguori, & Lugaresi, 1997).
Melatonin is a neurohormone that is synthesized from tryptophan and secreted by the pineal gland. It is involved in the regulation of circadian rhythms and the initiation of sleep (Lewy & Sack, 1989). In comparison with normal patients, insomniacs have suppressed nocturnal outputs of melatonin (Haimov et al., 1994; Hajak et al., 1995). Spence and colleagues (2004) showed acupuncture to significantly increase nocturnal endogenous melatonin secretion and therefore be effective in treating patients with insomnia.
The type of insomnia a person presents with determines their treatment. For example, a person suffering with transient insomnia would benefit from non-pharmacological treatment following good sleep hygiene. Pharmacological treatment would not be advised since the insomnia is generally short-term. For long-term chronic insomnia, if both medical and psychiatric conditions have been dismissed, behavioural or non-pharmacological treatments may be sought. However if these treatment options are unsatisfactory to the patient, pharmacological treatments may be used as an adjunct with non-pharmacological treatments (Maczaj, 1993). Current treatment options for insomnia comprise behavioural, pharmacological and/or alternative.
(a) Behavioural therapy
Cognitive behavioural therapy (CBT) is designed to change a patient’s perception or attitude about insomnia that may cause, or perpetuate it (Spielman, Caruso, & Glovinsky, 1987).
Jacobs and colleagues (2004) found that patients can achieve significantly greater results using CBT than pharmacotherapy and therefore, should be a first-line treatment for insomnia. Edinger and colleagues (2001) also found CBT to be efficacious for the treatment of insomnia. In addition, another study concluded that there was a significant preference by patients for the use of behavioural treatment over the use of pharmaceuticals products (Vincent & Lionberg, 2001). However one limitation of CBT is that it requires time and training to implement and relies on the patient to make a behavioural and/or lifestyle change.
(b) Pharmacological therapies
A lot of different classes of drugs over the years have been used to treat insomnia. Up until the 1970’s, barbiturates were the primary treatment for insomnia however they are now rarely used because of frequent adverse effects, rapid development of tolerance, risk of abuse and addiction with long-term use (Gillin & Byerley, 1990).
Antidepressants, such as trazodone, have also successfully been used to treat insomnia (Nierenberg, Adler, Peselow, Zornberg, & Rosenthal, 1994) however more studies are needed to ascertain their effects in non-depressed patients.
Historically, benzodiazepines have been the mainstay of treatment for insomnia due to their safety and proven efficacy (Maczaj, 1993) however Holbrook and colleagues (2000) reported that despite the fact they increase sleep duration, this is offset with the number of adverse side effects they present. A Cochrane Review also demonstrated that for insomnia in palliative care, no evidence was found for either the safety or efficacy of benzodiazepines (Hirst & Sloan, 2007).
Due to the negative side effect profile of benzodiazepines, selective non‑benzodiazepine agonists were developed. For this reason, they are now the most commonly prescribed sleep medication (Antai-Otong, 2006). The literature reports Zolpidem-MR to be a safe and effective non-benzodiazpeine agonist to treat primary insomnia by improving sleep maintenance, induction and duration of sleep (Roth, Soubrane, Titeux, & Walsh, 2006).
(c) Alternative therapies
Alternative therapies should be the first line of treatment for patients suffering with insomnia. Some of these therapies with proven efficacy include hypnosis which has been shown to be efficient therapy for school-age children with insomnia (Anbar & Slothower, 2006).
Shannahoff-Khalsa (2004) describes two meditation techniques known to be efficacious in the treatment of insomnia. One limitation of this however is that during the first 2-4 weeks of meditation, a worsening of sleep develops along with disturbing dreams. With continued long-term practice, the patient is able to achieve a deep and healthy sleep (Shannahoff-Khalsa, 2004).
The literature also reports that some patients perceive that chiropractic care will give them positive results for their insomnia (Jamison, 2005). However, there is no convincing, objective evidence to confirm this (Jamison, 2005).
3.3 Chinese Medicine Perspective
Within the concepts of traditional Chinese medicine (TCM), it is important to treat the person as a whole which includes the mind, body and spirit. The quintessential concept is not only to treat a disease as a lone entity but also to treat it as a complex picture. This enters into the idea that the root cause of the condition (the pattern) or the symptom (like insomnia) is considered as the branch of the disease. The root cause of the disease is the imbalance of the fundamental substances which include Yin, Yang, Qi, Xue, Jing, or Shén. To compound this idea, there is also the Zang organ system physiology to embrace, which involves the Heart, Spleen, Liver, Lung and Kidneys. There is an interplay of the fundamental substances with the physiological function of the Zang organs playing a major contributing factor, towards not only sleep quality and quantity, but to all facets of daily life. Classical TCM texts such as the Nei Jing Su Wen in Chapter 46 discussed the normal and abnormal courses of illness and explained that the Zang organs will be affected when insomnia is present, so to assist the condition of insomnia, the Zang must be nourished and re-established (Ni, 1995).
One of the first main and fundamental theoretical concepts of TCM is Yin and Yang. Yang is related to Qi, warmth, light, activity and daylight (sun travelling through the heavens) while Yin is akin to blood, nourishment, darkness, passiveness and night time (moon travelling through the night). The relationship between Yin and Yang manifest as the waxing and waning of day and night which is likened to the periodicity of circadian rhythms within the human body. The inability to sleep at night is a manifestation of unwarranted Yang during the Yin phase or simply a deficiency of Yin unable to counter the Yang. In addition, each organ has a time of the day when it is said to be at peak capacity. The time of the day the Gallbladder is at peak capacity is 11pm-1am whilst the time of day for peak capacity for the Liver is 1am-3am. Waking up at these times can indicate a deficiency of these organs which manifests as insomnia.
According to TCM, insomnia is defined as a disturbance of the Heart Shén (mind/spirit) (Maciocia, 1989). As described in the Huang Di Nei Jing (Chapter 23), the Heart is the housing for the Shén, which is one component of the five Zang organs (each of which contribute to the spirit) (Ni, 1995). The Heart and Liver or the Shén and Hun respectively, are the commonly affected organs in relation to the symptom of insomnia. The blood is said to return to the liver at night to be cooled so when there is heat in the blood, there will be disrupted sleep full of dreaming. In addition, if the Heart and Liver or Shén and Hun respectively are in a state of imbalance, there will be no grounding of the spirit, so the spirit is left to wander at night leading to insomnia.
To maintain good sleep within the concepts of TCM, the heart must be abundant with blood; any situation which disrupts the nourishment of the heart blood will also result in insomnia. Some of the pathology which can bring about insomnia or deficiency of blood include over-taxation or worrying, over-working, anger, irregular diet, child birth and pathological influences.
The emotion of the spleen is associated with worry and concentration thus when one worries excessively, the function of the spleen will be impeded. When the spleen is not functioning correctly, it cannot perform its job of producing blood, thus the heart will receive insufficient blood and the void may manifest as heart-fire. In the same light, over-working or over-concentration for long hours without rest can weaken the spleen and consume the kidneys, thus weakening the body. Chronic, prolonged use of the kidneys, in the long-term, dry-up or consume the Yin aspects which give rise to Yang rising. Within the five elements, the liver is associated with anger which can build into frustration and impede the flow of liver Qi exhibiting itself as patterns of Liver Yang rising or Liver fire (Hicks, Hicks, & Mole, 2004). This Liver Yang rising or Liver fire can be a stimulus for insomnia itself, or consume blood in the long-run and be a secondary causative factor.
In turn, a general over-consumption of food or eating sweet, greasy foods, can damage spleen function leading to the formation of damp and phlegm. This impedes the flow of Qi to the head to cause insomnia. During childbirth, large amounts of blood can be lost, which can be seen as a trauma on the body. If sufficient blood is not produced, the heart is starved of blood, giving rise to insomnia.
The invasion of the body by pathogens can also be a factor, such as wind-heat entering the body. This can manifest in both acute and chronic states of insomnia depending on the depth of invasion.
3.4 Differentiation of syndrome
A fundamental aspect of TCM involves the inter-relation of organs. This relationship of organs can sometimes malfunction giving rise to disease which can be caused by a Heart Spleen deficiency, Heart and Kidney disharmony, Heart Yin Deficiency, Phlegm Heat affecting the Shén or Hyperactivity of Liver Fire.
Heart Spleen Deficiency
The main signs and symptoms associated with Heart Spleen deficiency manifest themselves as the difficultly of initially falling into a state of sleep but once there is sleep the patient can maintain this state (The Ling Shu in Chapter 18 (Wu, 2004)). There can also be heart palpitations, impaired foggy memory, a pale facial complexion, undigested materials in faecal stools and a loss of appetite. The tongue would manifest as pale with a thin coating and the pulse would be weak.
As the heart is responsible for the storage of the Shen, as well as the circulation of blood throughout the body, a deficiency in the flow will manifest as palpitations and a pale facial complexion. Acupoints which are associated with assisting the condition of insomnia due to Heart Spleen Deficiency, include Shenmen (Ht7), Zusanli (St36), Sanyinjiao (Sp6) Pishu (Bl20) and Xinshu (Bl15) (Yin & Liu, 2000). These include the back transporting point of both the Heart and Spleen organs to assist in regulation, in addition to the use of Shenmen which is used extensively in journal literature for the condition of insomnia (Cui & Zhou, 2003; Kim et al., 2004; Lu, 2002; Phillips & Skelton, 2001; Shen, 2005; Zhang, 2003)
Heart Kidney Disharmony
Within the system of Wu Xing (five element), the kidney corresponds to the water element, whilst the heart corresponds to the fire element (Hicks, Hicks, & Mole, 2004). When the Water/Kidney Element is weak and unable to control the Heart Fire element via the controlling cycle, the Heart element will float up to disrupt the head. The symptoms associated with this include difficulty initially falling asleep or the inability to sleep at all; waking many times during the night as well as dream disturbed sleep. The accompanying signs and symptoms for the disharmony of the Heart and Kidney would be tinnitus, nocturnal perspiration, malar flushing, heat sensations in the palms and soles and thirst with ability to only consume small amounts of fluids. Acupoints which are associated with assisting the condition of insomnia due to Heart Kidney disharmony include Daling (Pc7) Taixi (Kd 3) Shenmen (Ht7) and Yongquan (Kd1) or Xinshu (Bl15), Shenshu (Bl23) (Flaws & Lake, 2001). Scalp head points such as Sishecong (HN-1) and Shenting (Du 24) are also used to assist with calming the mind and the combination of Shenmen (Ht 7) and in this instance, Zhaohai (Kd6) for the harmonization of Heart and Kidney (Yin & Liu, 2000).
Heart Yin Deficiency
Heart Yin deficiency is similar to that of Heart Blood deficiency, however an important difference between the two is that Heart Blood has difficulty initially falling asleep where as Heart Yin has both difficulty in initially falling asleep as well as maintaining sleep. Heart Yin deficiency will also show signs and symptoms of irritability, mental restlessness, palpitations, nocturnal perspiration, thirst, dry mouth, hot soles and palms, malar flush with a red tongue and tip without coating. Acupoints which are associated with assisting the condition of insomnia due to Heart Yin deficiency include YinXi (Ht6), XinShu (Bl 15), SanYinJiao (Sp 6) and Zhaohai (Kd6) (Flaws & Lake, 2001) with additional points accompanying symptoms. These can include palpitations Neiguan (Pc6) which is the Luo connecting point of the pericardium that has a direct influence on the state of the heart’s emotional and functional aspect (Deadman & Al-Khafaji, 1998). Therefore, is of benefit when in relation to cardiac function and Shén disruption. Interestingly, a study which utilised intradermal acupuncture application for patients with insomnia symptoms post stroke, found significant improvements when Neigaun (Pc 6) was coupled with Shenmen (Ht 7) (Kim et al., 2004).
Phlegm Heat affecting the Shen
This type of insomnia was discussed in the Nei Jing Su Wen, Chapter 34 on the conversation on imbalances (Ni, 1995) It discusses the function of the stomach, in relation to diet and the quality of sleep. The stomach does not have a storage function, but one of transportation to the lower organs of the body. Therefore, any stagnation of food due to an improper diet will have an effect on sleeping. Prolonged stagnation will result in the formation of phlegm and over time will condense to form heat. The Phlegm Heat will then follow the rebellious stomach Qi to affect the mind, thus giving the patient difficulty to lie in bed. The signs and symptoms associated with Phlegm Heat are difficulty in maintaining a restful sleep, profuse dreaming, tossing and turning in bed and a feeling of heat and heaviness of the body. Acupoints which are associated with assisting the condition of insomnia due to Phlegm Heat affecting the mind include Feng Long (St 40), ZhongWan (Du 12), LiDui (St 45) (Cui & Zhou, 2003; Lu, 2002) plus Shén calming additional points (Shenmen (Ht 7) and an extra point Anmian).
Hyperactivity of Liver Fire
The Liver and Gallbladder have a direct relation with emotions within the body so when anger or frustration are exhibited, there is a strong chance that a stagnation will lead to the fabrication and manifestation of Liver Yang rising or Liver fire symptoms. The main signs and symptoms in relation to the hyperactivity of Liver fire include restless sleep type insomnia, nightmares and irritability. The axillary signs and symptoms all have an aspect of heat, such as rapid wiry pulse, dry stools, dark urine thirst and dizziness (Maciocia, 1989). Both the channels ascend to merge at the head, and have an affinity with heat/fire, therefore temporal and apex headaches can accompany the insomnia. Acupoints which are associated with assisting the condition of insomnia due to Hyperactivity of Liver Fire include Xingjing (Lv2): used to drain the fire of the Liver, Taichong (Lv3) and Sanyinjiao (Sp6): used to nourish the Yin and calm the mind and Qiaoyin (Gb44): clearing the Liver and Gallbladder of heat and to assist with dream disturbed sleep (Deadman & Al-Khafaji, 1998; Maciocia, 2004). These combinations of points were also discussed in some TCM case studies (Lu, 2002; Zhang, 2003)
3.5 Acupuncture Points
Many points for insomnia can be used in acupuncture and include:
- Shen Men Ht 7 the Spirit gate: the Yuan source point, Shu stream point, the earth point and a draining point is one of the main points used in the treatment of insomnia (Deadman & Al-Khafaji, 1998). In Meridian/Japanese style acupunctures they tend not to use Shen Men but prefer to use points of the Pericardium channel (Pirog, 1996). This is probably due to the omission of the Heart channel in the Ling Shu (Chapter 5).
- AnMian (M-HN-17) Extra point, ‘Peaceful sleep’, a common clinical point for insomnia which lies slightly superiorly posteriorly close to Gb12 (Wan Gu) which is used for insomnia also (Denmei, 2003). The combination of SanYinJiao (Sp 6) and NeiGuan (Pc 6) is also recommended for insomnia (Deadman & Al-Khafaji, 1998).
3.6 Channel systems
Within the concept of the meridian theory, the eight extraordinary channels, in particular, the Yin Qiao Mai and Yang Qiao Mai have an affinity to influence sleep, so in turn, can influence insomnia. Chapter 80 of the Ling Shu described the symptomatology of insomnia as the presence of excessiveness within the Yang Qiao Mai coupled with a deficiency of the Yin Qiao Mai resulting in an inability to close the eyes (Pirog, 1996). The pathway of the Yin Qiao Mai terminates at the inner canthus of the eye whilst the Yang Qiao Mai crosses the eye (Yin & Liu, 2000). To balance this condition, Zhaohai (Kd 6), the master point of the Yin Qiao Mai, (coupled with Shenmen Ht 7) can be reinforced. A study by Hu and Zhuang (2002) illustrated this enabling the patient to be cured from insomnia.
Insomnia during pregnancy appears to be common with one study finding 88% of women to suffer changes in their sleep patterns (Suzuki, Dennerstein, Greenwood, Armstrong, & Satohisa, 1994). Guerreiro da Silva and colleagues (2005) have shown acupuncture to be efficacious and alleviate insomnia during pregnancy which is advantageous, especially since many women are adverse to taking medications whilst pregnant. However further studies using large, randomised cohorts and validated scales are required to validate this.
Clinical trials of acupuncture for insomnia have shown significant improvements in patients sleep who are suffering with the debilitating disease of HIV (Phillips & Skelton, 2001).
Acupressure has also been shown to significantly improve the sleep quality of elderly patients (Chen, Lin, Wu, & Lin, 1999).
A retrospective case study for the combination of scalp and body acupuncture was assessed. The four main differential patterns prevalent were the deficiency of Heart and Spleen, Heart and Kidney not communicating, the flaring up of Liver fire and the disharmony of Stomach (Lu, 2002). This study found that there was more of a tendency to favour a syndrome of excessiveness than deficiency (Lu, 2002). Scalp acupuncture was administered with the use of non-nomenclature Chinese scalp acupuncture (Yin & Liu, 2000) or the use of Yamamoto’s new scalp acupuncture (Freely, 2006). Accordingly, this case study is unable to be replicated unless the scalp acupoints were to be amended.
Microsystem acupuncture relates to the representation of somatotopic fields in accordance with specific points including the use of small areas to represent the rest of the body’s functional and pathological aspects (Hecker, Steveling, & Peuker, 2006). One of the most utilised microsystem acupuncture technique include the Chinese and Western schools of auricular acupuncture.
There are two main distinctive forms of auricular acupuncture, which are practiced, namely the Chinese system and that of the western Nogier (incorporating auricular geometry, auriculocardiac reflex and vascular autonomic signal) system of auricular therapy (Hecker, Steveling, & Peuker, 2006). The styles have in recent years integrated and transformed to gain beneficial adaptations. Auricular therapy incorporates the use of filiform and/or intradermal needles, herbal seeds, magnetic pellets, manual pressure, bleeding, moxibustion, electro acupuncture devices and lasers to stimulate the points within and around the auricle (ear) (Frank & Soliman, 2005)
Auricular therapy is a therapeutic method where specific acupoints on the auricle are stimulated to treat different disorders of the body (Suen, Wong, & Leung, 2001). Point selection is accomplished by compiling a group of points which correspond to either the TCM function or the modern clinical application (Chen, 2004). Suen and colleagues (2007; 2001) found that auricular therapy with magnetic pearls achieved significant sleep improvements (including both the quality and quantity of sleep) in the elderly providing them with a safer alternative for insomnia. However further research is needed to endorse these findings before a strong causal relationship can be established.
One study using otopoint pressure plus acupuncture treated 200 patients with 75% successfully cured from insomnia (Shen, 2005). In addition, the use of a semiconductor laser on auricular points has also been found to be suitable for the treatment of insomnia (Yao, 1999).
Western auricular acupuncture, use a collection of prescription points as a protocol for the treatment of insomnia. Some of the points include:
- Shenmen ear point which is the most utilised for its calming and tranquilising effects on the body.
- Insomnia points 1 and 2 which are self explanatory.
- Pineal Gland or “Point E” has a regulatory action and is considered as the bodies biological clock point (Frank & Soliman, 2005; Oleson, 2003).
The protocol also uses both the Chinese Heart and Kidney ear point for the balancing of the two organs as utilised for the function in TCM.
(c) Herbal medicine
TCM employs the use of herbs in conjunction with acupuncture to enhance and sustain the effects of acupuncture. The use of an herbal preparation in the treatment of insomnia is guided towards the nourishment of the Zang organs more so than acupuncture. For the treatment of insomnia, some possible herbal preparations used following pattern differentiation include the following.
Gui Pi Tang (restore the spleen Decoction) has historically been modified many times over to its present state. It was first presented in the Song dynasty 1253 ADE by Yan Yang-He in the Ji Sheng Feng (Formulas to Aid the Living) as a Spleen and Heart tonic, injured by chronic pensiveness, for the conditions of anxiety and forgetfulness (Frank & Soliman, 2005). It was further developed in the Shi Yi De Xiao Fang (Effective formulas from generations of physicians), complied by Wei Yi-Lin in 1345 (Yuan Dynasty) to include bleeding due to a spleen Qi deficiency. The modern day application relates to insomnia, which was documented during the Ming Dynasty in the 16th century mentioned in the Jiao Zhu Fu Ren Liang Fang (Revised fine formulas for women) by Bi Li- Zhai including two extra herbs: a Shén calmer and a blood nourisher, Yuan Zhi (Radix Polygalae Tenuifoliae) and Dang Gui (Radix Angelicae Sinensis). Yuan Zhi was included to assist with heart shén disruption whilst Dang Gui was used to assist with the spleen’s blood formation aspect.
The herbal classic Jin Gui Yao Lue (Essentials from the Golden Cabinet) by Zhang Zhong Jing first mentioned Suan Zao Ren Tang (Sour Jujube decoction) in the Eastern Han dynasty for the inability to sleep, palpitation nocturnal perspiration and sensations of vertigo and dizziness (Bensky & Randall, 1990). The actions of this formula are to nourish the Heart blood and calm the Shén as well as clearing heat and eliminating irritability, thus assisting with insomnia (Bensky & Randall, 1990).
Ding Zhi Wan (Settle the emotions Pill) was originally used in the Qian Jin Yao Fang (Thousand Ducat Formulas) to tonify the Heart Qi and calm the Shén.
Zhi Zi Dou Chi Tang (Gardenia and prepared soy bean decoction), present in the Shan Han Lun, Eastern Han Dynasty, was used to clear heat lingering in the superficial Qi level of the Yang Ming and alleviate states of restlessness and irritability.
A study has shown that using modern Chinese herbal formulations, including Zhen Xin An Shen Tang (Sedate the Heart and calm the spirit Decoction) and Anmian Wan (Sleeping pills) were able to assist in alleviating insomnia (Bensky & Randall, 1990).
Another study found that a herbal supplement (which contained, among other things valerian), proved beneficial to patients suffering with insomnia, avoiding the negative side effects of commonly prescribed hypnotics (Fruehauf, 1995).
The studies discussed above have shown that although Western pharmaceutical medications can be efficacious for the treatment of insomnia, there are also serious adverse side effects which can be detrimental to the body. In addition, some people including the elderly, pregnant women and people suffering with diseases such as AIDS or cancer are unable or unwilling to take medication. Because of this, another type of therapy is needed. Several studies have shown acupuncture to be efficacious in the treatment of insomnia (Lu, 2002; Sok, Erlen, & Kim, 2003; Xia, Li, & Huang, 2006). More importantly, acupuncture is generally regarded as a safe and cost effective form of treatment.
Unlike the idea of contemporary allopathic medicine which investigates the micro aspect of the patient, the art form of TCM sees the patient as a “macro whole” entity, not just directing treatment to the symptom of “insomnia”. TCM will concentrate treatments efforts towards the balancing of fundamental substances, physiological aspects of Zang Fu Organs and equilibrium of the channels. Therefore, when prescribing treatment, different points and/or therapy are utilised. For that reason, treatment options will always be different for different patients, despite the fact that both may suffer from insomnia. This is one main advantage of acupuncture over Western medicine however clinical studies of acupuncture lack scientific merit as a protocol of treatment is difficult to sustain.
Despite the results of numerous acupuncture studies showing efficacy for the treatment of insomnia, these results cannot be generalised due to many differences including differences in the selection criteria of subjects, acupoints used and type of acupuncture. Also, many of the studies were not randomised therefore an amount of bias limits its effectiveness. Future, large, well designed, controlled studies (with the use of sham acupuncture), following STRICTA guidelines, are needed to critically evaluate acupuncture and insomnia.
American Academy of Sleep Medicine. (2001). International Classification of Sleep Disorders Diagnostic and Coding Manual (Second ed.). Illinois: American Academy of Sleep Medicine.
Anbar, RD, & Slothower, M. (2006). Hypnosis for treatment of insomnia in school-age children: a retrospective chart review. BMC Pediatrics, 6(23).
Antai-Otong, D. (2006). The art of prescribing. Risks and benefits of non-benzodiazepine receptor agonists in the treatment of acute primary insomnia in older adults. Perspectives in Psychiatric Care, 42(3), 196-200.
Bensky, D, & Randall, B. (1990). Chinese Herbal Medicine Formulas & Strategies. Seattle: Eastland Press.
Chen, ML, Lin, LC, Wu, SC, & Lin, JG. (1999). The effectiveness of acupressure in improving the quality of sleep of institutionalized residents. The Journals of Gerontology, 54A(8), M389-M394.
Cui, R, & Zhou, D. (2003). Treatment of Phlegm and Heat induced insomnia by Acupuncture in 120 cases. Journal of Traditional Chinese Medicine, 23(1), 57-58.
Culebras, A. (2007). Sleep disorders and neurologic diseases (2nd ed.). New York: Informa Healthcare.
Deadman, P, & Al-Khafaji, M. (1998). A Manual of Acupuncture. East Sussex: Journal of Chinese Medicine Publications.
Denmei, S. (2003). Finding effective acupuncture points (S. Brown, Trans.). Seattle Eastland Press.
Dowling, GA, Mastick, J, Colling, E, Carter, JH, Singer, CM, & Aminoff, MJ. (2005). Melatonin for sleep disturbances in Parkinson’s disease. Sleep Medicine, 6, 459-466.
Edinger, J, Wohlgemuth, W, Radtke, R, Marsh, G, & Quillian, R. (2001). Cognitive Behavioral Therapy for Treatment of Chronic Primary Insomnia: A Randomized Controlled Trial. Journal of the American Medical Association, 285(14), 1856-1864.
Flaws, B, & Lake, J. (2001). Chinese Medical Psychiatry. Boulder: Blue Poppy Press.
Frank, B, & Soliman, N. (2005). Auricular Therapy. Bloomington: AuthorHouse Publications.
Freely, R. (2006). Yamamoto New Scalp Acupuncture. New York: Thieme Medical Publishers.
Fruehauf, H. (1995). Mental Disorders. Journal of Chinese Medicine, 48(May), 21-34.
Gillin, JC, & Byerley, WF. (1990). The diagnosis and management of insomnia. New England Journal of Medicine, 322, 239-248.
Guerreiro da Silva, JB, Nakamura, MU, Cordeiro, JA, & Kulay, L. (2005). Acupuncture for insomnia in pregnancy – a prospective, quasi-randomised, controlled study. Acupuncture in Medicine, 23(2), 47-51.
Haimov, I, Laudon, M, Zisapel, N, Souroujon, M, Nof, D, Shlitner, A, & Herer, P. (1994). Sleep disorders and melatonin rhythms in elderly people. British Medical Journal, 309(6948), 167.
Hajak, G, Rodenbeck, A, Staedt, J, Bandelow, B, Huether, G, & Ruther, E. (1995). Nocturnal plasma melatonin levels in patients suffering from chronic primary insomnia. Journal of Pineal Research, 19, 116-122.
Hecker, HU, Steveling, A, & Peuker, ET. (2006). Microsystem Acupuncture. Stuttgart: Thieme Publications.
Hicks, A, Hicks, J, & Mole, P. (2004). Five Element Constitutional Acupuncture. Edinburgh: Churchill Livingstone.
Hirst, A, & Sloan, R. (2007). Benzodiazepines and related drugs for insomnia in palliative care (Review). The Cochrane Collaboration(1), 1-21.
Holbrook, AM, Crowther, R, Lotter, A, Cheng, C, & King, D. (2000). Meta-analysis of benzodiazepine use in the treatment of insomnia. Canadian Medical Association Journal, 162(2), 225-233.
Hu, D, & Zhuang, Q. (2002). Clinical experience in application of the point Zhaohai. Journal of Traditional Chinese Medicine, 22(3), 218-220.
Jacobs, GD, Pace-Schott, P, Stickgold, R, & Otto, MW. (2004). Cognitive Behavior Therapy and Pharmacotherapy for Insomnia. Archives of Internal Medicine, 164, 1888-1896.
Jamison, JR. (2005). Insomnia: Does Chiropractic Help? Journal of Manipulative and Physiological Therapeutics, 28(3), 179-186.
Kim, Y, Lee, S, Jung, W, Park, S, Moon, S, Ko, C, Cho, K, & Bae, H. (2004). Intradermal Acupuncture on Shen-Men and Nei Kuan Acupoints in Patients With Insomnia After Stroke. The American Journal of Chinese Medicine, 32(5), 771-778.
Lewy, AJ, & Sack, RL. (1989). The dim light melatonin onset as a market for circadian phase position. Chronobiology International, 6, 93-102.
Lu, Z. (2002). Scalp and Body Acupuncture for the treatment of Senile Insomnia. Journal of Traditional Chinese Medicine, 23(3), 193-194.
Maciocia, G. (1989). The Foundations of Chinese Medicine. Edinburgh: Churchill Livingstone.
Maciocia, G. (2004). Diagnosis in Chinese Medicine A Comprehensive Guide. Edinburgh: Churchill Livingstone.
Maczaj, M. (1993). Pharmacological treatment of insomnia. Drugs Aging, 45, 44-45.
McCurry, SM, Logsdon, RG, Vitiello, MV, & Teri, L. (2004). Treatment of sleep and nightmare disturbances in Alzheimer’s disease: a behaviour management approach. Sleep Medicine, 5, 373-377.
Milligan, SA, & Chesson, AL. (2002). Restless Legs Syndrome in the Older Adult Diagnosis and Management. Drugs Aging, 19(10), 741-751.
Montagna, P, Provini, F, Plazzi, G, Liguori, R, & Lugaresi, E. (1997). Propriospinal myoclonus upon relaxation and drowsiness: a cause of severe insomnia. Movement Disorders, 12(1), 66-72.
Ni, M. (1995). The Yellow Emperor’s Classic of Medicine. Boston: Shambhala.
Nierenberg, AA, Adler, LA, Peselow, E, Zornberg, G, & Rosenthal, M. (1994). Trazodone for antidepressant associated insomnia. American Journal of Psychiatry, 151(7), 1069-1072.
Oleson, T. (2003). Auriculotherapy manual Chinese and Western systems of ear acupuncture (Third ed.). Edinburgh: Churchill Livingstone.
Phillips, KD, & Skelton, WD. (2001). Effects of individualised acupuncture on sleep quality in HIV disease. Journal of the Association of Nurses in AIDS care, 12(1), 27-39.
Pirog, J. (1996). The Practical Application of Meridian Style Acupuncture. Berkeley Pacific View Press.
Roth, T, Soubrane, C, Titeux, L, & Walsh, JK. (2006). Efficacy and safety of zolpidem-MR: a double-blind, placebo-controlled study in adults with primary insomnia. Sleep Medicine, 7(5), 397-406.
Saper, CB, Scammel, TE, & Lu, J. (2005). Hypothalamic regulation of sleep and circadian rhythms. Nature, 437, 1257-1263.
Shannahoff-Khalsa, DS. (2004). An introduction to Kundalini Yoga Meditation Techniques that are specific for the treatment of psychiatric disorders. The Journal of Alternative and Complementary Medicine, 10(1), 91-101.
Shen, P. (2005). Two hundred cases of insomnia treated by otopoint pressure plus acupuncture. Journal of Chinese Medicine, 77, 168-169.
Shneerson, JM. (2005). Sleep Medicine A Guide to sleep and its disorders (Second ed.). Massachusetts: Blackwell Publishing, Inc.
Smith, MT, Perlis, ML, Chengazi, VU, Pennington, J, Soeffing, J, Ryan, JM, & Giles, DE. (2002). Neuroimaging of NREM sleep in primary insomnia: A Tc-99-HMPAO single photon emission computed tomography study. Sleep, 25(3), 325-335.
Sok, SR, Erlen, JA, & Kim, KB. (2003). Effects of acupuncture therapy on insomnia. Journal of Advanced Nursing, 44(4), 375-384.
Spence, D.W, Kayumov, L, Chen, A, Lowe, A, Jain, U, Katzman, MA, Shen, J, Perelman, B, & Shapiro, CM. (2004). Acupuncture increases nocturnal melatonin secretion and reduces insomnia and anxiety: a preliminary report. Journal of Neuropsychiatry and Clinical Neurosciences, 16, 19-28.
Spielman, AJ, Caruso, LS, & Glovinsky, PB. (1987). A behavioral perspective on insomnia treatment. Psychiatric Clinics of North America, 10, 541-553.
Stepanski, E, Zorick, F, Roehrs, T, Young, D, & Roth, T. (1988). Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. Sleep, 11(1), 54-60.
Suen, LKP, Wong, TKS, & Leung, AWN. (2001). Is there a place for auricular therapy in the realm of nursing? Complementary Therapies in Nursing & Midwifery, 7, 132-139.
Suzuki, S, Dennerstein, I, Greenwood, KM, Armstrong, SM, & Satohisa, E. (1994). Sleeping patterns during pregnancy in Japanese women. Journal of Psychosomatic Obstetrics and Gynecology, 15(1), 19-26.
Vincent, N, & Lionberg, C. (2001). Treatment preference and patient satisfaction in chronic insomnia. Sleep, 24(4), 411-417.
Wu, J. (2004). Ling Shu or The Spiritual Pivot Honolulu: University of Hawaii Publication.
Xia, D, Li, M, & Huang, Y. (2006). A clinical observation of treating 128 cases of teenage insomnia with acupuncture and moving cupping. International Journal of Clinical Acupuncture, 15(3), 151-154.
Yao, S. (1999). 46 cases of insomnia treated by semiconductor laser irradiation on aruricular points. Journal of Traditional Chinese Medicine, 19(4), 298-299.
Yin, G, & Liu, Z. (2000). Advanced Modern Chinese Acupuncture. Beijing: New World Press.
Zhang, Q. (2003). Clinical observation on acupuncture treatment of insomnia in 35 cases Journal of Traditional Chinese Medicine, 23(2), 125-126.