Phân loại chứng mất ngủ sử dụng hệ thống Trung Y: Bài báo đánh giá có hệ thống trong thuốc thay thế và bổ sung dựa trên bằng chứng

Phân loại chứng mất ngủ sử dụng hệ thống y học cổ truyền Trung Quốc: Bài báo đánh giá có hệ thống trong thuốc thay thế và bổ sung dựa trên bằng chứng · Tháng 7 năm 2012 DOI: 10.1155 / 2012/735078 · Nguồn: PubMed CITATIONS READS 14 2.479 tác giả, bao gồm: Maggie MK Poon Wing Fai Yeung Đại học Hồng Kông Đại học Bách khoa Hồng Kông CÔNG TÁC 185 CÔNG TÁC 105 CÔNG TÁC 1.962 CÔNG TÁC XEM HỒ SƠ XEM HỒ SƠ Verdi HK Yau Shi Ping Zhang Đại học Hồng Kông Đại học Baptist Hồng Kông XUẤT BẢN 14 CÔNG TÁC 53 CÔNG KHAI 1.808 CÔNG TÁC XEM HỒ SƠ XEM HỒ SƠ Một số tác giả của ấn phẩm này cũng đang thực hiện các dự án liên quan này: Châm cứu để giảm đau do dùng Benzodiazepine dài hạn: A Dự án xem thử có đối chứng ngẫu nhiên Tất cả nội dung sau trang này được tải lên bởi Wing Fai Yeung vào ngày 30 tháng 6 năm 2014 Người dùng đã yêu cầu nâng cao tệp tải xuống Tiêu đề Tác giả (Các) Phân loại chứng mất ngủ sử dụng hệ thống chẩn đoán y học cổ truyền Trung Quốc: đánh giá có hệ thống Poon, Man -ki; Trích dẫn Ngày phát hành URL Quyền 2010 http://hdl.handle.net/10722/57704 Không hạn chế Phân loại chứng mất ngủ sử dụng hệ thống chẩn đoán Y học cổ truyền Trung Quốc: Một đánh giá có hệ thống của POON Man Ki (潘敏琪) BCM, HKU Một luận án được đệ trình hoàn thành một phần Các yêu cầu đối với Bằng Thạc sĩ Khoa học Y tế tại Đại học Hồng Kông Tháng 12 năm 2009 Mục tiêu Tóm tắt: Các đánh giá trước đây về chẩn đoán bệnh mất ngủ của Y học Cổ truyền Trung Quốc (TCM) bị giới hạn trong việc tìm kiếm không có hệ thống các tài liệu tiếng Trung hoặc một hội chứng TCM cụ thể mẫu Do đó, một đánh giá toàn diện về văn học tiếng Trung và tiếng Anh đã được tiến hành để xem xét việc phân loại chứng mất ngủ bằng hệ thống chẩn đoán TCM Phương pháp: Chúng tôi thực hiện đánh giá có hệ thống tất cả các nghiên cứu về chứng mất ngủ sử dụng hệ thống chẩn đoán TCM Hai nhà nghiên cứu độc lập chịu trách nhiệm thu hồi giấy tờ giai đoạn, dữ liệu từ tập hợp các giấy tờ liên quan cuối cùng được trích xuất bằng cách sử dụng standa Biểu mẫu trích xuất dữ liệu rdized Kết quả: Tìm kiếm mang lại 4795 tiêu đề bài báo tiềm năng; Sau khi xem xét các tiêu chí đưa vào và loại trừ của chúng tôi để lựa chọn giấy, tổng số 103 nghiên cứu và 9499 đối tượng mất ngủ đã được đưa vào đánh giá giai đoạn hai Chúng tôi tìm thấy tổng cộng 69 dạng hội chứng TCM khác nhau đối với chứng mất ngủ. Dạng phổ biến nhất là Thiếu cả tim tỳ vị hư nhược được nói đến trong 93,2% số bài, tiếp theo là Chứng hư hỏa do âm hư (63,1%), Gan khí ngưng trệ chuyển hóa thành hỏa khí (42,7%), Nội nhiệt đờm nhiệt (34,0%), Suy tim - thận (30,1%) và thiếu hụt Qi của tim và túi mật (29,1%) Mặc dù chỉ có các mẫu chẩn đoán TCM được liệt kê trong sách giáo khoa tiêu chuẩn về TCM, đánh giá của chúng tôi cho rằng không có tim - thận, không được liệt kê trong sách tiêu chuẩn , được xếp hạng giữa các mẫu chẩn đoán TCM phổ biến thứ hai đến thứ sáu theo các tiêu chí lựa chọn khác nhau Chúng tôi đã tìm thấy 23 thuật ngữ khác nhau cho các triệu chứng liên quan đến giấc ngủ và 89 các triệu chứng không liên quan đến giấc ngủ khác nhau liên quan đến wi Các mô hình hội chứng TCM đối với chứng mất ngủ Các triệu chứng liên quan đến giấc ngủ phổ biến nhất trong các tài liệu về bệnh TCM là giấc ngủ bị rối loạn giấc mơ, dễ thức giấc và ngủ không yên giấc Các triệu chứng không liên quan đến giấc ngủ phổ biến nhất là chóng mặt, hồi hộp và trí nhớ kém Ngoài ra còn có Các đặc điểm về lưỡi và mạch được đề cập trong tài liệu về bệnh TCM Chúng tôi nhận thấy một số điểm trùng lặp về triệu chứng và dấu hiệu giữa các mô hình TCM phổ biến đối với chứng mất ngủ Ví dụ, giấc ngủ bị rối loạn giấc mơ và chóng mặt có trong các mô hình phổ biến nhất So sánh các mẫu TCM với chẩn đoán mất ngủ theo phân loại của phương Tây hệ thống, chúng tôi phát hiện ra rằng chứng mất ngủ nguyên phát có thể kết hợp với chứng Thiếu cả tim và lá lách và chứng Tâm hỏa do thiếu âm; mất ngủ liên quan đến rối loạn lo âu tương thích với thiếu khí của tim và túi mật và gan-khí ngưng trệ chuyển hóa thành hỏa; mất ngủ liên quan đến rối loạn trầm cảm có thể giống như thiếu Qi của tim và túi mật; trong khi mất ngủ do tắc nghẽn hội chứng ngưng thở khi ngủ có một số điểm tương đồng với Thiếu cả tim Kết luận: Chúng tôi đã xác định được một số dạng hội chứng TCM phổ biến liên quan đến chứng mất ngủ đáng được nghiên cứu thêm, đặc biệt, chứng tim-thận không được liệt kê trong Sách giáo khoa về bệnh TCM Một số triệu chứng liên quan đến giấc ngủ bao gồm giấc ngủ bị rối loạn giấc mơ và giấc ngủ không yên không được sử dụng thường xuyên trong các hệ thống chẩn đoán phương Tây, nhưng thường được đề cập trong hệ thống bệnh TCM. Cần phải xem xét thêm tầm quan trọng lâm sàng của các triệu chứng liên quan đến giấc ngủ. Đánh giá của chúng tôi cho thấy rằng nhiều thuật ngữ Trung Quốc khác nhau đã được sử dụng trong tài liệu về TCM để mô tả hiện tượng tương tự

Classification of Insomnia Using the Traditional Chinese Medicine System: A Systematic Review

Article  in   Evidence-based Complementary and Alternative Medicine · July 2012

DOI: 10.1155/2012/735078 · Source: PubMed

CITATIONS

14

READS 2,479

5 authors, including:

Some of the authors of this publication are also working on these related projects:

Electroacupuncture for Tapering off Long-Term Benzodiazepine Use: A Randomized Controlled Trial View project

Author(s) Poon, Man-ki; 潘敏琪

Citation

Classification of insomnia using Traditional Chinese Medicine diagnostic system:

A systematic review

by

POON Man Ki (潘敏琪) BCM, HKU

A thesis submitted in partial fulfillment of the requirements for

the Degree of Master of Medical Sciences

at The University of Hong Kong

December 2009

Abstract

Objective: Previous reviews regarding Traditional Chinese Medicine (TCM) diagnosis

for insomnia were either limited to non-systematic search of Chinese language

literature or a particular TCM syndrome pattern A comprehensive review of Chinese

and English language literatures was therefore conducted to review the classification

of insomnia using TCM diagnostic system

Methods: We performed systematic review of all studies on insomnia that used TCM

diagnostic system Two independent researchers were responsible for paper retrieval

At the second phase, data from the final set of relevant papers was extracted using a

standardized data extraction form

Results: The search yielded 4795 potential articles titles; after going through our

inclusion and exclusion criteria for paper selection, a total of 103 studies and 9499

insomniac subjects were included in the second phase review We found a total of 69

different TCM syndrome patterns for insomnia The most common pattern was

Deficiency of both the heart and spleen, which was mentioned in 93.2% of the articles,

followed by Hyperactivity of fire due to yin deficiency (63.1%), Liver-qi stagnation

transforming into fire (42.7%), Internal disturbance of phlegm-heat (34.0%), Heart-kidney noninteraction (30.1%) and Qi deficiency of the heart and gallbladder

(29.1%) Although only 5 TCM diagnostic patterns are listed in the standard TCM

textbook, our review suggested that Heart-Kidney noninteraction, which was not

listed in the standard textbook, was ranked between second to sixth commonest TCM

diagnostic patterns by different selection criteria We found 23 different terms for

sleep-related symptoms and 89 different non-sleep-related symptoms associated with

the TCM syndrome patterns for insomnia The most common sleep-related symptoms

in the TCM literature were dream-disturbed sleep, easy awakening from sleep and

restless sleep The most common non-sleep-related symptoms were dizziness,

palpitation and poor memory There were also tongue and pulse features mentioned in

the TCM literature We found some overlaps in symptom and sign among the

common TCM patterns for insomnia For example, dream disturbed sleep and

dizziness were present in 5 of the 6 most common patterns Comparing TCM patterns

with insomnia diagnoses in the Western classification systems, we found that primary

insomnia can probably be matched with Deficiency of both the heart and spleen and

Hyperactivity of fire due to yin deficiency; insomnia related to anxiety disorders is

compatible with Qi deficiency of the heart and gallbladder and Liver-qi stagnation

transforming into fire; insomnia related to depressive disorder may resemble Qi deficiency of the heart and gallbladder; while insomnia due to obstructive sleep apnea

syndrome has some similarities with Deficiency of both the heart

Conclusion: We identified some common TCM syndrome patterns related to insomnia

that were worthy of further studies, in particular, Heart-Kidney noninteraction, which

was not listed in the TCM textbook Some sleep-related symptoms including dream

disturbed sleep and restless sleep are not frequently used in the Western diagnostic

systems, but are commonly mentioned in the TCM system It is worthwhile to further

examine the clinical importance of those sleep-related symptoms Our review showed

that many different Chinese terms were used in the TCM literature to describe similar

phenomenon This lack of standardization in the terminology can definitely affect the

scientific studies of TCM Lastly, we found some similarities between the TCM and

Western classification for insomnia Further studies are needed to examine the

integration of TCM and Western classification systems in the diagnosis of insomnia

disorder

Declaration

I declare that the thesis hereby submitted for the Degree of Master of Medical

Sciences at the University of Hong Kong is my own work and has not been previously

submitted by me at another University for any degree I cede copyright of the thesis in

favor of the University of Hong Kong

Acknowledgements

I would like to gratefully acknowledge the enthusiastic supervision of Prof KF Chung

during my research I thank Mr Jerry Yeung for the technical discussions and advice

on data retrieval methodology In particular, I would like to acknowledge the help of

Mr Verdi Yau for data extraction and database analysis model

I am grateful to all my friends at the Faculty of Medicine, University of Hong Kong,

for being my surrogate family during the many years I stayed there and for their

continuous moral support thereafter

Finally, I am forever indebted to my family for their understanding, endless patience

and encouragement when it was most required

1.6 Qi, Blood and Body-fluid Differentiation 12

1.7 Zang Fu Organs Differentiation 13

1.8 Classification of insomnia using TCM diagnostic system 15

2.2 Paper selection process 20

2.3 Data extraction process 21

3.2 Description of the included studies 22

3.3 Types of study 23

3.5 Diagnosis of insomnia disorders 23

3.6 TCM syndrome diagnostic patterns mentioned in the reviewed papers

List of Figures and Tables

Figure 1 Selection of trials for inclusion in the review 59

Table 1 Studies reviewed for TCM diagnostic pattern of insomnia 60

Table 2 Diagnostic criteria for insomnia used in the 103 included

Table 3.1 The top 10 TCM syndrome diagnostic patterns used in the

103 reviewed papers (Total N = 103) 67

Table 3.2 The top 12 TCM syndrome diagnostic patterns in subjects

with insomnia in the 26 reviewed RCT paper (Total N = 26) 68

Table 3.3

The top 11 TCM syndrome diagnostic patterns in subjects with insomnia in the 46 reviewed paper with impact factor above 0.5 (Total N = 17)

69

Table 3.4 The top 10 most common TCM syndrome diagnostic

patterns in subjects with insomnia (Total N = 9499) 70

Table 4 Summary of the TCM syndrome diagnostic patterns in Table

Table 5 Sleep-related symptoms in the top 6 TCM syndrome

diagnostic patterns for insomnia (Total N = 37) 72

Table 6 Non-sleep-related symptoms in the top 6 TCM syndrome

diagnostic patterns for insomnia (Total N = 37) 74

Table 7 Tongue features in the top 6 TCM syndrome diagnostic

patterns for insomnia (Total N = 37) 79

Table 8 Pulse features in the top 6 TCM syndrome diagnostic

patterns for insomnia (Total no of paper = 37) 80

Table 9

TCM syndrome diagnostic patterns according to “Traditional Chinese Internal Medicine” recommended by the Ministry of Health of China

Chapter 1

Introduction

1.1 Definition of insomnia

According to the American Academy of Sleep Medicine Work Group, the research

diagnostic criteria for insomnia include one or more of the following sleep related

complaints: difficulty initiating sleep, difficulty maintaining sleep, waking up too

early or sleep that is chronically nonrestorative or poor in quality The above sleep

difficulties occur despite adequate opportunity and circumstances for sleep Moreover,

at least one or more of the following forms of daytime impairment related to the

nighttime sleep difficulties are reported by the individual: fatigue or malaise; attention,

concentration or memory impairment; social or vocational dysfunction or poor school

performance; mood disturbance or irritability; daytime sleepiness; motivation, energy

or initiative reduction; proneness for errors or accidents at work or while driving;

tension headaches and/or gastrointestinal symptoms in response to sleep loss; and

concerns or worries about sleep1

In the revised edition of the International Classification of Sleep Disorders (ICSD),

more than 100 differential diagnoses of insomnia are listed 2 The recent report of the

American Academy of Sleep Medicine Work Group found that several insomnia

phenotypes that appear most valid and defensible1 Standardized research criteria for

the most valid phenotypes are developed, which include primary insomnia, insomnia

due to a mental disorder, psychophysiological insomnia, paradoxical insomnia,

idiopathic (childhood onset) insomnia, insomnia related to periodic limb movement

disorder, insomnia related to sleep apnea, insomnia due to medical condition, and

insomnia due to drug or substance2

1.2 Epidemiology of insomnia

Concluding from more than 50 studies of insomnia based on data collected in various

representative community-dwelling samples,about one-third of the general population

presents at least one of the insomnia symptoms3.If daytime consequences of insomnia

are taken into account, the prevalence of insomnia is between 9% and 15%3 The

prevalence of insomnia disorder according to the Diagnostic and Statistical Manual of

Mental Disorders, Forth Edition (DSM-IV) criteria is roughly 6% 3.Moreover, there is

a trend of increasing insomnia symptoms with age; women are shown to have a higher

prevalence of insomnia than men 3

1.3 Traditional Chinese Medicine (TCM) theory of insomnia

TCM is one of the longest history medical systems in the world Over the past two

thousand years, the TCM medical system has become more conceptual and less

technologically driven while the TCM treatment becomes more individualistic than

Western medical therapies The TCM theory originates from doctors’ experience on

patients in ancient times 4; some TCM diagnostic issues regarding insomnia are not

considered in Western medicine theory

In term of the TCM theory, insomnia is due to a disharmony of Yin and Yang in their

daily cycle in human body Quoting from chapter 80 of “Spiritual Axis” in “Huang Di

Nei Jing”: “If Defensive Qi does not enter into Yin at night and remains in Yang,

Yang-Qi will become full and Yang Qiao Mai in excess, Yin becomes deficient and the

eyes cannot close.”5 There is physiological decline of Qi and Blood in the elderly;

they normally have less sleep than younger people Chapter 18 of “Spiritual Axis” in

“Huang Di Nei Jing” says: “Young people have abundant Qi and Blood … they are

energetic in the daytime and sleep well at night Old people have declining Qi and

There are other quotes in TCM literature mentioned about sleep disturbances Chapter

34 of “Simple Questions” in “Huang Di Nei Jing” says: “If Stomach is not in peace,

sleep will not sound.”6 Body position also has a significant implication in sleep If a

person could not sleep in a supine position, it means an excess condition, usually the

Lung or Heart Chapter 46 of “Simple Questions” in “Huang Di Nei Jing” says: The Lung is the “lid” of the other organs When Lung-Qi is in excess, the Channels and Blood Vessels are full and the person cannot lie on his back This condition often

occurs in asthma patients, for example, when the Lung is obstructed by Phlegm If a

person can only sleep on one side, it indicates that there is either a deficiency of Qi

and Blood on that side of the body or an excess Qi and Blood on the opposite side

This condition especially applies to problems related to the Heart or Lung and can be

checked by testing the pulse By rolling the finger medially and laterally on the Lung

pulse, one can feel the state of Qi in right (lateral) and left (medial) Lung If there is

an imbalance in pulse, the person is only able to sleep on the Deficiency side 6

In term of TCM theory, noisy breathing is usually due to Phlegm affecting the

Stomach Channel or caused by rebellious Qi in the three Yang Channels of the leg

Chapter 34 of “Simple Questions” in “Huang Di Nei Jing” says: “Those who suffer

from rebellious Qi cannot sleep well and have noisy breathing; this is due to

rebellious Qi in the Yang Ming Channels When the Qi of the three Yang Channels of

the leg cannot flow down and rebels upwards, it causes insomnia and noisy

breathing.”6

Sleep problems are mentioned in TCM literatures two thousand years ago5-6 TCM is

largely based on philosophical concepts Sophisticated and interconnected systems

work in balance to maintain the healthy function of the human body5-6 Although most

of the TCM concepts cannot be proven by scientific methods, the diagnostic system of

the TCM continues to be practiced nowadays

1.4 TCM diagnostic approach

TCM diagnostic process relies entirely on recognition of clinical symptoms by the

practitioners The use of technological aids to verify the findings is seldom necessary

The two diagnostic approaches in TCM are “disease differentiation” and “syndrome

differentiation”7 Disease differentiation aims to identify different diseases, for

example, stroke, diabetes, frozen shoulder or insomnia disorder Syndrome

differentiation aims to identify different patterns of disease and provide specific

treatment plan There are four diagnostic techniques - observation, auscultation and

olfaction, interrogation and palpation7 Practitioners discern subtle symptoms and

signs, and describe patients’ disharmony using the TCM diagnostic pattern that most

interferes with optimal state of wellness7

1.5 Syndrome differentiation

Syndrome differentiation describes patients’ disharmony in term of eight parameters:

diagnostic patterns are given by a combination of the above eight parameters and

others principles, such as Qi, Blood and Body-fluid differentiation, Zang Fu Organ

differentiation7 Using these different parameters and principles, the TCM syndrome

diagnostic pattern can be worked out Overall, the TCM diagnosis is characterized by

its comprehensive symptom-based approach and emphasis on imbalance of body

elements and functional status Because the diagnosis is based on the presence of a

group of subtle symptoms and signs, changes in only one symptom or sign can alter

the diagnostic pattern In addition, the TCM diagnostic pattern can change over time8

Yin and Yang are complementary opposites within a greater whole Everything has Yin

and Yang aspects that constantly interact and never exist in absolute stasis Yin and

Yang have several properties: opposing to each other, rooted together, transformed to

each other, and are in a dynamic equilibrium External refers to skin and hair while

Internal refers to internal organs, bone marrow, Qi and blood Excess is usually

caused by pathogenic factors; while Deficiency refers to dysfunction or lowering of

body function Hot refers to heat due to Yang excess or Yin Deficiency; while Cold

can be due to Yang Deficiency or Yin Excess7

1.6 Qi, Blood and Body-fluid Differentiation

According to TCM theory, Qi refers to the essential energy flow that maintains the

vital body function If Qi is Excess or Deficiency, it may cause energy-related

disorders Disorder of the flow of Qi may cause stagnation, which can transform into

Blood is the most important nutrient that maintains vital body function According to

TCM theory, Spleen produces Blood and is responsible for the normal function of

Blood Blood is stored in the Liver, while Heart governs Blood Vessels The pathology

of Blood includes Blood Deficiency, Blood Stasis and Bleeding9

Body-fluid includes Phlegm and Fluids Phlegm can be tangible or intangible The

symptoms of Phlegm Excess may include chest oppression, gastric fullness, nausea,

vomiting, diarrhea, vertigo, palpitation, skin numbness, joint swelling, subcutaneous

lumps and mania Phlegm Excess results from dysfunction of the Lung, Spleen and

Kidney or Fire due to Yin Deficiency of the Zang Fu organs After mixing with Qi,

1.7 Zang Fu organs Differentiation

Zang Fu organs are consisted of five “Zang” and six “Fu” The five “Zang” refers to Liver, Heart, Spleen, Lung and Kidney, while the six “Fu” refers to Large intestine, Small intestine, Gall bladder, Stomach, Urinary bladder and Pericardium The

common sleep abnormalities involve dysfunction of Spleen, Stomach, Liver,

Spleen and Stomach work together to generate Qi and Blood from food Spleen

controls Blood and governs the transportation and transformation of the water, food

and body fluids Spleen-Qi Deficiency may cause bleeding and retention of water

(tangible or intangible) Stomach governs the intake and decomposition of food

Either dysfunction of Spleen or Stomach can cause malnutrition of the body Worry,

over thinking, overwork will harm the Spleen and Stomach 9

Liver governs the flow of Qi Emotional distress can cause damage to the Liver

Chronic Liver-Qi stagnation, Liver-Blood Deficiency, Liver-Yin Deficiency, Liver-Fire

and Liver-Yang Excess are common Liver problems that cause insomnia9

Phlegm Fire and Gallbladder-Qi Deficiency are common causes of insomnia caused

by Gallbladder problem Gallbladder Overact may cause Fire, while Fire consumes

Fluids and produces Phlegm Phlegm-Fire always disturbs the Heart, which results in

insomnia Gallbladder is responsible for decision making Gallbladder-Qi Deficiency

may cause difficulty in decision making, which may cause insomnia Gallbladder is

attached to the Liver; hence problems of Liver may lead to Gallbladder problems9

Kidney is considered as the congenial base, which stores the primordial Yin and Yang

and Essence that are essential for the human growth Constitutional weakness,

overstrain, and malnutrition due to chronic disease will damage the Yin, Yang and

Essence of the Kidney The pathology of Kidney includes Kidney-Qi Deficiency, Kidney-Yin Deficiency, Kidney-Yang Deficiency and Kidney-Yin-Yang Deficiency and

Heart governs Blood Vessels and stores the Mind Pericardium is the outside

protection of the Heart; hence it is sometimes attacked by exogenous pathogenic

factors, e.g., insomnia occurring after a contagious disease is always caused by

residue of pathogens in the Pericardium Heart Deficiency mostly refers to Heart-Yin

1.8 Classification of insomnia using TCM diagnostic system

The recognition of insomnia as a major medical problem by TCM practitioners has

been more than 2000 years The first written text about insomnia is Huang Di Nei Jing

first published around 100B.C , insomnia was classified as the disharmony of Yin and

Yang, disharmony in stomach, due to aging or secondary to other diseases such as

cough, vomit 5-6 Zhang Zhongjing (~220) classified insomnia into two types:

External and Internal 10 Dai Yuenli (~1400) states insomnia mainly classified into two

types, first type is due to sickness or Yang Deficiency caused by aging, second type is

due to Disturbance of phlegm in Gall bladder causing Deficiency in Heart Qi 11

Zhang Jiebin (1624) classified insomnia into with or without exogenous factors,

insomnia caused by exogenous factors mostly are expressed in excess syndrome and

for all insomnia not caused by exogenous factors are expressed in deficiency

syndrome 12 Li Zhongzi (1637) first classified insomnia into five syndromes clearly:

Deficiency of Qi, Deficiency of Yin, Stagnation of Phlegm, Water distention, Stomach

insomnia found that there were 45 possible TCM syndrome patterns14 The standard

textbook Traditional Chinese Internal Medicine recommended by the Ministry of

Health of China listed five TCM syndrome diagnostic patterns of insomnia9 Another

standard textbook Internal Medicine of Traditional Chinese Medicine also listed five

TCM syndrome diagnostic patterns15; however, the two standard textbooks used

different terminology for the diagnostic patterns The five TCM syndrome diagnostic

patterns listed in Traditional Chinese Internal Medicine are Liver-qi stagnation

transforming into fire, Internal disturbance of Phlegm-Heat, Deficiency of both the heart and spleen, Hyperactivity of fire due to yin deficiency and Heart-gallbladder qi Deficiency The first two syndrome diagnostic patterns are Excess patterns, while the

other three are Deficiency patterns9

The common sleep problems of Liver-qi stagnation transforming into fire include

sleeplessness and dream disturbed sleep, while the common symptoms and signs are

irritability, thirst with desire to drink water, hypochondriac distension, poor appetite,

red face, bitter taste, constipation and bloody urine The tongue feature is red tongue

with a yellow coating, and the pulse is wiry and rapid The treatment principle is to

clear the Liver Fire and calm the Heart Mind 9

Regarding Internal disturbance of phlegm-heat, the common sleep problem is

sleeplessness Other common symptoms and signs include heavy sensation in the head

profuse sputum, chest stuffiness, nausea, belching, restlessness, bitter taste and

blurred vision The tongue features are red with a yellow and greasy coating The

pulse is slippery and rapid The treatment principle is to resolve Phlegm, clear Heat

and calm the Mind 9

The common sleep problem of Deficiency of both the heart and spleen is dream

disturbed sleep, while other common symptoms and signs include palpitation, poor

memory, dizziness, blurred vision, weakness of the limbs, lassitude, poor appetite and

lusterless complexion The tongue features are pale tongue with thin and white

coating The pulse is thready and weak The treatment principle is to tonify the Heart

and Spleen, nourish Blood and calm the Mind 9

For Hyperactivity of fire due to yin deficiency, the common sleep problems are

restlessness and sleeplessness and other common symptoms and signs include

palpitation, uneasiness, dizziness, tinnitus, poor memory and weakness in the lumbar

region and knee joints, feverish sensation in the palms, soles and chest, and dry mouth

The tongue is red with scanty coating The pulse is thready and rapid The treatment

principle is to nourish Yin, reduce Fire, nourish the Heart and calm the Mind 9

The common sleep problems of Qi deficiency of the heart and gallbladder are

sleeplessness, dream disturbed sleep and frequent waking with a start Other common

symptoms and signs are timidity, palpitation, susceptibility to fright, shortness of

breath, lassitude and clear and profuse urine The tongue is pale and the pulse is wiry

and thready The treatment principle is to supplement Qi, relieve fright and calm the

Mind 9

There are some problems with TCM syndrome diagnostic pattern, including the lack

of standardization in the terminology of symptoms and signs and the lack of

agreement between TCM practitioners in the presence or absence of specific

symptoms and signs Another problem is the lack of standardization in the

terminology of syndromes Overall, the agreement between practitioners in syndrome

diagnostic pattern and treatment recommendation remains uncertain

TCM is one of the longest history medical systems in the world, however further

development is hindered by the lack of standardization in the terminology of

symptoms, signs and syndrome diagnostic patterns As many studies of TCM

diagnostic patterns on insomnia have been published in Chinese and English scientific

literatures, and have not been systematic reviewed, it is therefore worthwhile to

undertake a systematic review on the TCM diagnostic patterns of insomnia

1.9 Aim of study

We aimed to find out the most common TCM diagnostic patterns given by TCM

practitioners for subjects with insomnia and the core symptoms and signs agreed by

TCM practitioners for the TCM diagnostic patterns We would also compare the TCM

diagnostic patterns with the insomnia phenotypes of the Western diagnostic system

Chapter 2

Methods

This systematic review used a 2-stage approach The first stage was to retrieve

relevant literatures and textbooks using a standardized search strategy The second

stage was to retrieve the information regarding TCM diagnostic issues of insomnia

using a standardized record form

2.1 Databases searched

We searched the English language literatures using computerized databases, including

the Cochrane Central Register of Controlled Trials (CENTRAL) (1999-2009),

MEDLINE (1966-2009), EMBASE (1980-2009), PsycINFO (1887-2009), PUBMED

(1948-2009), Dissertation Abstracts International (1861-2009), Cumulative Index to

Nursing and Allied Health Literature (CINAHL) (1982-2009), Allied and

Complementary Medicine Database (AMED) (1985-2009), National Center for

Complementary and Alternative Medicine (1991-2009), and National Institute of

Health Clinical Trials Database (1997-2009) The keywords used were “Chinese

Medicine or TCM or acupunc* or acupress* or electroacupunc* or meridian* or

acupoint* or tuna*” and “sleep* or insomnia* or wakeful* or sleepless* or

somnambul*” The reference lists of the retrieved papers were further searched for

relevant articles

We searched the China Journals Full-text Database from inception in 1915 to

November, 2008 Equivalent Chinese terms that were used to search the English

language databases are “中醫 or 中藥 or 針 or 推拿 or 穴 or 經絡 or 證型 or

診斷 or 辨證 or 分類” and “失眠 or 不寐 or 不得臥 or 睡眠困難” The China Journals Full-text Database was one of the major Chinese language literature

databases containing over 1143 medical journals including 129 major TCM journals

The reference lists of the retrieved papers were further searched for relevant articles

Studies included in this review were clinical trials that examined participants with

chief complaint of insomnia who have been classified with TCM diagnostic patterns

The participants using TCM treatments, placebo, Western medication or no treatment

will be included We did not set any specification for the treatments, outcome

measures, study quality and validity for our review

2.2 Paper selection process

The authors (M.K.P and H.K.Y.) searched the databases and independently examined

titles and abstracts of the retrieved papers and selected all potentially relevant

publications The investigators were not blind to the authors’ name and affiliation, or

journal name Full paper of the relevant publications were obtained and reviewed in

details against the inclusion and exclusion criteria We included all studies involving

participants with a chief complaint of insomnia The exclusion criteria were: (1)

discussion papers or magazine articles; (2) studies with less than 30 subjects; (3)

studies of male or female only; (4) studies that focus on a specific medical and

psychiatric condition; (5) studies that focus on a particular life transition period; (6)

studies that focus on subjects aged >70 or <18 years; (7) studies that focus on a

specific TCM diagnostic pattern; (8) studies without statistical information regarding

TCM diagnostic pattern; and (9) duplicate publications reporting the same group of

participants The authors then discussed the selected articles; any disagreement about

the eligibility of articles was resolved by consensus and a final set of relevant papers

was confirmed

We have excluded those papers on either sex, specific medical/ psychiatric conditions,

life transition period and a specific TCM pattern were excluded in order to obtain a

representative picture of the frequency of various TCM syndrome for insomnia

Further studies may be needed to examine specific diagnostic pattern in specific

patient groups

2.3 Data extraction process

At the second phase, data from the final set of relevant papers was extracted using a

standardized data extraction form Study design, diagnostic criteria, participants’

characteristics including mode of recruitment, sampling procedure, inclusion and

exclusion criteria, number of subjects, age and sex distribution, duration of insomnia

and TCM diagnostic patterns including types of TCM diagnosis, symptoms of each

TCM diagnosis were extracted All Chinese to English translations in this paper were

deduced from the book Traditional Chinese Internal Medicine published by People’s

Medical Publishing House in 20079 and WHO International Standard Terminologies

on Traditional Medicine in the Western Pacific Region published by World Health

Organization in 200716

Chapter 3

Results

3.1 Excluded papers

The search yielded 4795 potential articles titles for review; of which 1058 articles

were duplicate papers (Figure 1) A total of 1972 articles were excluded for reasons of

irrelevancy to insomnia or TCM; while 336 articles were excluded due to non-study

design Among the remaining 1423 studies, 95 studies with subjects aged below 18 or

above 70 years, 33 studies focus on either male or female only, 73 studies focus on a

specific medical and psychiatric condition, and 19 studies focus on a particular life

transition period There were 145 papers focusing on a specific TCM diagnostic

pattern, 264 papers with less than 30 subjects, and 364 studies without specific TCM

diagnostic patterns In addition, 16 papers were written neither in Chinese nor English,

310 studies without statistical information regarding TCM diagnostic pattern, and 1

paper could not be retrieved in full text A total of 103 studies were included in this

review17-119 Full details of the excluded studies are available from the authors upon

request

3.2 Description of the included studies

Table 1 presents the characteristics of the 103 reviewed studies17-119 Sample size of

the studies ranged from 30 to 856, with a total of 10035 subjects A total of 56.5% of

the sample was female The mean age of the subjects was 44.0 years, based on the 51

studies that had the demographic data The duration of insomnia reported in the

reviewed studies ranged from 3 days to 51 years The 103 reviewed studies were all

conducted in China; only 5 studies (4.9%) were published in English language

literature

3.3 Types of study

Twenty-six (25.2%) of the 103 reviewed studies were RCT, 12 (11.7%) were

controlled non-randomized studies, 16 (15.5%) were case studies, 48 (46.6%) were

uncontrolled trials, and 1 (1.0%) was an epidemiological study

3.4 Types of journal

The 103 reviewed studies were published in 63 different journals; 7 studies were

extracted from English computerized databases, 96 studies were extracted from China

Journals Full-text Database Fifty-two of the 63 journals (82.5%); of which 85

reviewed studies were published, were known to have impact factor; while 17 journals

had impact factor higher than 0.5120

3.5 Diagnosis of insomnia disorders

Ninety-nine of the 103 reviewed studies (96.1%) had not used structured interview,

questionnaires, or polysomnography for the assessment of insomnia disorder Only 4

studies27, 65, 69-70 reported the use of standardized assessment procedure Gao27 and

Shi65 used the Pittsburgh Sleep Quality Index (PSQI)121 to assess the severity of

insomnia Tian70 used the Spiegel Sleep Questionnaire122 Tang69 used

polysomnography for diagnosis and assessment of insomnia

Table 2 presents the diagnostic criteria for insomnia used in the reviewed studies

Sixty-nine of 103 studies (67.0%) mentioned that TCM diagnosis was based on the

criteria of a particular textbook Twelve of the 103 studies (11.7%) used the insomnia

criteria of the Diagnosis and Therapeutic Effect of Diseases and Syndromes in

Traditional Chinese Medicine (TCM-NJ) published by the State Administration of

Traditional Chinese Medicine of the People’s Republic of China123, which include: (1)

either difficulty falling asleep, frequent awakening, or difficulty falling asleep after

awakening, and (2) the sleep disturbance is the patients’ major concern and is

associated with daytime consequences The TCM-NJ criteria further classifies

insomnia into different subtypes based on TCM theory

Eleven of the included studies (10.7%) used the criteria for insomnia in the Chinese

Classification of Mental Disorder (CCMD) published by the Chinese Psychiatric

Association124, which include: (1) either difficulty falling asleep, frequent dreaming or

early awakening that occurs at least three nights per week for at least 1 month, and (2)

the sleep disturbance is the patients’ major concern and is associated with daytime

consequences

Nine studies used the Clinical Research Guidelines of New Chinese Herbal Medicine

(CRG) for diagnosis of insomnia; it includes a quantitative criterion of total sleep time

less than five hours per day and classifies insomnia into different subtypes based on

TCM theory125 One study used both the CCMD and CRG as diagnostic criteria, two

studies used Hollister Diagnostic Criteria126, one study used the diagnostic criteria

published by the World Health Organization and one of the TCM textbook -

report the diagnostic criteria used None of the studies used DSM-IV criteria for

diagnosis of insomnia disorders Although both TCM-NJ and CRG criteria use

quantitative measures to define insomnia, the rest of their criteria are no different

from other traditional TCM diagnostic criteria

3.6 TCM syndrome diagnostic patterns mentioned in the reviewed papers

A total of 74 different TCM syndrome patterns were reported in the 103 reviewed

papers The number of TCM syndrome patterns used in individual study varied from 2

to 7 We found that some syndrome patterns were similar, for example, Heart

deficiency with timidity (心虛膽怯) and Heart-gall bladder deficiency and timidity

(心膽虛怯) After grouping similar TCM syndromes as one single syndrome, we

found 69 different TCM syndrome patterns as etiology of insomnia Table 3.1 shows

the 10 most common TCM syndrome patterns The six most common patterns were

Deficiency of both the heart and spleen (93.2%), Hyperactivity of fire due to yin deficiency (63.1%), Liver-qi stagnation transforming into fire (42.7%), Internal disturbance of phlegm-heat (34.0%), Heart-kidney noninteraction (30.1%) and Qi deficiency of the heart and gallbladder (29.1%)

3.7 TCM syndrome diagnostic patterns in RCT study design papers and papers

published in high impact factor journals

We found 28 different TCM syndrome patterns mentioned in the 26 included papers

with RCT study design In order to compare the number of TCM syndrome patterns

for insomnia in RCT study design papers vs non-RCT papers, we randomly selected

26 of the 77 non-RCT papers for the comparison We found 34 different TCM

syndrome patterns, which was slightly greater than the number of TCM patterns in

RCT papers Table 3.2 presents the 12 most common TCM syndrome diagnostic

patterns reported in the RCT papers The six most common patterns were Deficiency

of the heart and spleen (92.3%), Hyperactivity of fire due to yin deficiency (61.5%), Liver-qi stagnation transforming into fire (50.0%), Heart-kidney noninteraction

(38.5%), Internal disturbance of phlegm-heat (34.6%), Heart deficiency with timidity

(23.1%) and Qi deficiency of the heart and gallbladder (23.1%)

Researches of the high quality papers and RCT studies were probably more stringent

in the diagnostic process; hence, they tend to follow the major diagnostic system with

the hypothesis number of TCM syndrome less than other papers Table 3.3 presents

the top 11 TCM syndrome diagnostic patterns in the 17 papers that were published in

journals with impact factor ≥0.5 We found that the papers with impact factor ≥0.5 had included 32 TCM syndrome diagnostic patterns In order to compare the number

of TCM syndrome patterns for insomnia in papers with impact factor ≥0.5 vs papers with no impact factor or impact factor <0.5, we randomly selected 17 of the 86 papers

with no impact factor or impact factor <0.5 for the comparison We found 16 different

TCM syndrome patterns in the papers published in journals with no or low impact

factor, which was much less than that the number of syndrome patterns in papers with

impact factor ≥0.5 The six most common TCM syndrome patterns in the papers published in journals with impact factor ≥0.5 were Deficiency of both the heart and

spleen (94.1%), Heart-kidney noninteraction (52.9%), Hyperactivity of fire due to yin deficiency (41.2%), Liver-qi stagnation transforming into fire (35.3%), Qi deficiency

of the heart and gallbladder (29.4%) and Internal disturbance of phlegm-heat

(23.5%)

3.8 TCM syndrome diagnostic patterns in subjects with insomnia

A total of 9499 subjects in the reviewed studies had data on their TCM syndrome

diagnostic patterns Table 3.4 presents the 10 most common TCM syndrome patterns

in subjects with insomnia The most common pattern was Deficiency of both the heart

and spleen, which was diagnosed in 2365 subjects (25.0%), followed by Hyperactivity

of fire due to yin deficiency (17.1%), Liver-qi stagnation transforming into fire (9.7%), Heart-kidney noninteraction (8.1%), Qi deficiency of the heart and gallbladder (5.7

%), and Internal disturbance of phlegm-heat (4.9%) About 70% of the subjects were

diagnosed with Deficiency of both the heart and spleen, Hyperactivity of fire due to

yin deficiency, Liver-qi stagnation transforming into fire, Heart-kidney noninteraction, Internal disturbance of phlegm-heat, or Qi deficiency of the heart and gallbladder –

the 6 most common syndrome diagnostic patterns; and roughly 10% of the subjects

were diagnosed with the next 5 most common syndrome patterns

Table 4 shows a summary of the top 10 TCM syndrome diagnostic patterns in

different types of paper The top 6 patterns were the same regardless of the type of

papers, namely Deficiency of both the heart and spleen, Hyperactivity of fire due to

yin deficiency, Liver-qi stagnation transforming into fire, Heart-kidney noninteraction, Internal disturbance of phlegm-heat, and Qi deficiency of the heart and gallbladder

or Heart deficiency with timidity

3.9 Clinical features of the TCM syndrome diagnostic patterns

Thirty-seven reviewed papers had presented the symptoms and signs of individual

TCM syndrome diagnostic patterns Most of the terminology of the symptoms and

signs were in Chinese We translated all the Chinese terms to English Table 5

presents the sleep-related symptoms of the 6 most common TCM syndrome

diagnostic patterns There were a total of 51 different Chinese terminologies for

sleep-related symptoms; some of them appeared to be very similar For example, 入

睡困難, 不易入寐, 不易入睡, 難以入眠, and 難以入睡 were used to describe difficulty falling asleep After grouping some similar Chinese terminologies, the

number of terminology in English for the sleep-related symptoms was 23 We further

simplified the 23 different terminologies in English by grouping some similar terms,

for example, sometimes shallow sleep and shallow sleep, frequently wakes up with a

start and sometimes wakes up with a start, late night difficulty in falling asleep and

difficulty in falling asleep Finally, we found 21 terminologies in English for the

sleep-related symptoms The most frequently mentioned sleep-related symptom in the

TCM syndrome diagnostic patterns was dream-disturbed sleep (43.6%), followed by

easy awakening from sleep (34.3%), restless sleep (21.3%), and difficulty falling

asleep (13.9%)

There were a total of 158 different Chinese terminologies for non-sleep-related

symptoms; some of them also appeared to be very similar The number of different

terminologies in English for the non-sleep-related symptoms was reduced to 109 We

grouped some similar English terminologies, for example, little saliva and dry mouth,

loss of strength and tiredness, reduction in luster complexion and lusterless

complexion Finally, we found 89 terminologies in English for the non-sleep-related

symptoms The most frequently mentioned non-sleep-related symptom was dizziness

(53.7%), followed by palpitation (44.4%), poor memory (42.6%), restlessness

(32.4%), bitter taste (28.7%), tinnitus (28.7%), blurred vision (26.9%), lassitude of

spirit (26.9%), sore waist (24%), and feverish sensations in the palms, soles and chest

(21.3%)

There were 18 different Chinese terminologies for the tongue features; after

translation into English, it was reduced to 13 The most frequently mentioned tongue

feature was red tongue (50%), followed by pale tongue (36.2%), yellow coating

(29.6%), thin coating (26.9%), slimy coating (13.9%), scanty coating (11.1%), and

white coating (10.2%)

There were 7 different pulse features in both Chinese and English terminologies The

most frequent pulse feature was thready pulse (66.7%), followed by rapid pulse

(52.8%), weak pulse (28.7%), wiry pulse (25%), and slippery pulse (14.8%)

3.10 Clinical features of TCM syndrome patterns based on our review vs TCM

textbook description

We summarized the common sleep-related, non-sleep-related, tongue and pulse

features of the top 6 TCM diagnostic patterns reported in the reviewed papers (Table

9) Table 10 presents the TCM syndrome diagnostic patterns according to the

textbook Traditional Chinese Internal Medicine recommended by the Ministry of

Health of China 9

For the syndrome Deficiency of both the heart and spleen, the most common

sleep-related symptoms found in our review were easy awakening from sleep (80.0%)

and dream-disturbed sleep (74,3%) The common non-sleep-related symptoms were

palpitation (82.9%), lassitude (80%), poor memory (74.3%), reduction in luster

complexion or lusterless complexion (62.9%), dizziness (60%), blurred vision

(42.9%), lack of strength (40%), tasteless (31.4%) and fatigue of the limbs (22.9%)

The common tongue features were pale tongue (85.7%) with thin (65.7%) coating

The common pulse features were thready pulse (85.7%) and weak pulse (82.9%)

The clinical features of Deficiency of both the heart and spleen based on our review

were mostly similar to those listed in the textbook Traditional Chinese Internal

Medicine Easy awakening from sleep, lassitude of spirit, tasteless were found in our

review but not in the textbook; whereas poor appetite was mentioned in the textbook

but not in our review

Based on our review, dream-disturbed sleep (85.7%) and frequent awakening with a

start (57.1%) were the most common sleep-related symptoms of Qi deficiency of the

heart and gallbladder The common non-sleep-related symptoms included palpitation

(100%), susceptibility to fright (100%), timidity (85.7%), shortness of breath (57.1%),

tiredness (57.1%), prolonged and clear urine (42.9%) The common tongue feature

was pale tongue (70.0%) The pulse was reported to be thready (100.0%) and wiry

(70.0%) The clinical features of Qi deficiency of the heart and gallbladder based on

our review were the same as the textbook description

Our review showed that, for Liver-qi stagnation transforming into fire, difficulty

falling asleep (31.6%) and dream-disturbed sleep (10.5%) were the most common

sleep-related symptoms; non-sleep-related symptoms included irritability (89.5%),

bitter taste (84.2%), constipation (73.7%), reddish eyes (68.4%), yellow urine (52.6%),

agitation (52.6%), hypochondriac distension (47.4%), headache (42.1%), thirst

(36.8%), restlessness (36.8%), dizziness (31.6%), impatience (26.3%), red face

(26.3%), poor appetite (21.1%), oppression in the chest (21.1%), and tinnitus (21.1%)

The tongue was reported to be red (89.5%) and had yellow coating (84.2%) The

common pulse features were rapid (94.7%) and wiry pulse (89.5%) Comparing the

textbook description with our review, some of the clinical features were the same,

such as dream-disturbed sleep, irritability, bitter taste, constipation, thirst,

hypochondriac distension, poor appetite, red face, red tongue with yellow coating,

rapid and wiry pulse According to our review, difficulty falling asleep, reddish eyes,

agitation, headache, restlessness, dizziness, impatience, oppression in the chest,

tinnitus, and yellow urine were used to describe Liver-qi stagnation transforming into

fire, but they were not mentioned in the textbook, while bloody urine was mentioned

in the textbook but not in our review

Our review showed that restless sleep (41.7%), easy awakening from sleep (33.3%),

dream-disturbed sleep (29.2%), sometimes shallow sleep (12.5%) were the most

common sleep-related symptoms of Hyperactivity of fire due to yin deficiency; other

symptoms were tinnitus (83.3%), poor memory (79.2%), palpitation (79.2%),

dizziness (75%), dry mouth (70.8%), sore waist (54.2%), restlessness (50%), feverish

sensations in the palms, soles and chest (75.0%), scant fluid (41.7%), emission of

semen during dreaming (20.8%), acid regurgitation (16.7%), dry throat (16.7%), and

sweating (16.7%) The tongue was reported to be red (83.3%) with scanty coating

(33.3%) The common pulse features were thready (87.5%) and rapid pulse (83.3%)

Comparing the textbook description with our review, some of the terms were the same,

such as restless sleep, tinnitus, poor memory, palpitation, dizziness, dry mouth,

soreness and weakness in the lumbar region and knee joints, restlessness, feverish

sensations in the palms, soles and chest, red tongue with scanty coating, thready and

rapid pulse However, easy awakening from sleep, dream-disturbed sleep, sometimes

shallow sleep, emission of semen during dreaming, acid regurgitation and sweating

found in our review were not mentioned in the textbook

For Internal disturbance of phlegm-heat, we found that restless sleep (46.2%) was the

most common sleep-related symptom; other symptoms were restlessness (100%),

blurred vision (100%), oppression in the chest (84.6%), profuse sputum (76.9%),

bitter taste (92.3%), dizziness (61.5%), stuffiness in the stomach (46.2%), anguish in

the heart (46.2%), heavy sensation in the head (30.8%), acid regurgitation (23.1%),

anorexia (23.1%), belching (23.1%) The tongue was reported to be red (69.2%) and

with yellow slimy coating (92.3%) The common pulse features were slippery

(100.0%) and rapid pulse (84.6%) Comparing the textbook description with our

review, some of the terms were the same, such as restlessness, blurred vision, profuse

sputum, bitter taste, belching, heavy sensation in the head and oppression in the chest,

red tongue with yellow slimy coating, slippery and rapid pulse Similar symptoms

included nausea in the textbook and stuffiness in the stomach in our review Some

clinical features found in our review, such as restless sleep, anguish in the heart,

dizziness acid regurgitation and anorexia were not mentioned in the textbook

For Heart-kidney noninteraction, our review showed that restless sleep (30%) and

dream-disturbed sleep (20%) were the most common sleep-related symptoms; other

symptoms were tinnitus (60%), dizziness (50%), feverish sensations in the palms,

soles and chest (40%), palpitation (40%), night sweating (30%), emission of semen

(30%), restlessness (20%) and restlessness of deficiency type (20%) The common

tongue feature was red tongue (70.0%) The pulse was reported to be thready (100.0%)

and rapid (70.0%) This pattern was not included in the textbook Traditional Chinese

Internal Medicine as a TCM diagnostic pattern for insomnia Heart-kidney noninteraction was ranked 4th among the common TCM diagnostic patterns

prescribed in subjects with insomnia and accounted for 8.1% among 9499 patients

complaining of insomnia (Table 3.4)

3.11 Comparing the clinical features among the top 6 TCM syndrome diagnostic

patterns

We found that some sleep-related symptoms, such as dream-disturbed sleep, restless

sleep, easy awakening from sleep were found in more than 1 TCM syndrome patterns

We found that dream-disturbed sleep was found in 5 of the 6 most common patterns,

except Heart-Kidney noninteraction; restless sleep was present in Internal

disturbance of phlegm-heat, Hyperactivity of fire due to yin deficiency, and Heart-kidney noninteraction; while easy awakening from sleep was present in Deficiency of both heart and spleen and Hyperactivity of fire due to yin deficiency

Three sleep-related symptoms were only present in 1 pattern The symptom

sometimes shallow sleep was mentioned in Hyperactivity of fire due to yin deficiency,

difficulty falling asleep in Liver-qi stagnation transforming into fire and frequent

awakening with a start in Qi deficiency of the heart and gallbladder

Comparing the non-sleep-related symptoms among the top 6 TCM diagnostic patterns,

we found that dizziness, palpitation, restlessness, tinnitus, acid regurgitation, bitter

taste, blurred vision, oppression in the chest, poor memory, and feverish sensations in

the palms, soles and chest were present in more than 1 TCM syndrome patterns

Dizziness was present in 5 of the 6 patterns, except Qi deficiency of the heart and

gallbladder Palpitation was present in the 4 deficiency patterns Restlessness was

found in the 2 excess patterns, Hyperactivity of fire due to yin deficiency and

Heart-kidney noninteraction Tinnitus was present in Liver-qi stagnation transforming into fire, Hyperactivity of fire due to yin deficiency and Heart-kidney noninteraction Acid regurgitation, bitter taste, and oppression in the chest were

present in the 2 excess patterns Blurred vision was present in Internal disturbance of

phlegm-heat and Heart-kidney noninteraction Feverish sensations in the palms, soles

and chest were present in Hyperactivity of fire due to yin deficiency and Heart-kidney

noninteraction Poor memory was found in Deficiency of both the heart and spleen

and Hyperactivity of fire due to yin deficiency

Some symptoms were found in 1 pattern only Anguish in the heart, anorexia,

belching, heavy sensation in the head, profuse sputum and stuffiness in the stomach

were found in Internal disturbance of phlegm-heat Agitation, constipation, headache,

hypochondriac distension, impatience, irritability, poor appetite, red face, reddish eyes,

thirst and yellow urine were found only in Liver-qi stagnation transforming into fire

Fatigue of the limbs, lack of strength, lassitude, reduction in luster complexion or

lusterless complexion and tasteless were present in Deficiency of both the heart and

spleen Emission of semen and night sweating were found in Heart-kidney noninteraction These 2 symptoms, emission of semen and night sweating were also

found in Hyperactivity of fire due to yin deficiency, but with a slightly different term,

emission of semen during dream and sweating Other symptoms only found in

Hyperactivity of fire due to yin deficiency were dry mouth or throat, scant fluid and

sore waist Prolonged and clear urine, shortness of breath, susceptibility to fright,

timidity and tiredness were found only in Qi deficiency of the heart and gallbladder

The tongue features of the 2 excess patterns were red tongue with yellow coating,

however, the tongue feature in Internal disturbance of phlegm-heat was different from

that in Liver-qi stagnation transforming into fire because the former pattern had a

slimy tongue coating Red tongue was also found in deficiency patterns with Yin

Deficiency, including Hyperactivity of fire due to yin deficiency and Heart-kidney noninteraction, but the former pattern had a scanty coating Pale tongue was present

in both Deficiency of both the heart and spleen and Qi deficiency of the heart and

gallbladder, but the former pattern had thin and white tongue coating

The pulse feature of the 2 excess TCM syndrome patterns was rapid pulse, while in

the 4 deficiency patterns; the pulse feature was fine pulse Rapid pulse also found in

the 2 Yin deficiency patterns, Hyperactivity of fire due to yin deficiency and Heart-

kidney noninteraction The pulse features of Deficiency of both the heart and spleen

and Qi deficiency of the heart and gallbladder were different from those in other

deficiency patterns because the former had weak pulse, while the latter had wiry

pulse

3.12 TCM syndrome diagnostic patterns for insomnia vs Western insomnia

diagnoses

There are many diagnostic systems for insomnia, such as the DSM-IV, ICD-10 and

ICSD-2 This review only compared the TCM syndrome patterns with the DSM-IV

classification system We focused on 6 most common DSM-IV insomnia diagnoses,

namely, primary insomnia, substance-induced sleep disorder – insomnia type,

insomnia related to another mental disorder – anxiety disorders, insomnia related to

another mental disorder – depressive disorder, insomnia due to a general medical

condition, and insomnia due to specific sleep disorders, e.g OSAS, PLMD

Primary insomnia

Comparing the common TCM syndrome patterns of insomnia with the DSM-IV

primary insomnia, we found that difficulty initiating sleep was similar to difficulty

falling asleep in Liver-qi stagnation transforming into fire; difficulty maintaining

sleep in the DSM-IV system was similar to easy awakening from sleep in Deficiency

of both the heart and spleen and Hyperactivity of fire due to yin deficiency;

nonrestorative sleep was comparable to lassitude, lack of strength, fatigue of limbs in

also states that sleep disturbance and the associated daytime fatigue causes clinically

significant distress or impairment in social, occupational, or other important areas of

functioning These daytime symptoms of primary insomnia are comparable to the

non-sleep-related symptoms in the TCM syndrome patterns The tongue and pulse

features mentioned in the TCM patterns are not reported in the DSM-IV primary

insomnia diagnosis As a whole, all common TCM syndrome patterns for insomnia

seem to be compatible with the DSM-IV primary insomnia diagnosis

Substance-induced sleep disorder – insomnia type

The DSM-IV diagnosis of substance-induced sleep disorder – insomnia type would

require the subjects’ sleep disturbance to be sufficiently severe to warrant independent

clinical attention and there is evidence from the history, physical examination, or

laboratory findings that the sleep disturbance is developed during, or within a month

of, substance intoxication or withdrawal; or medication use is etiologically related to

the sleep disturbance Moreover, the sleep disturbance causes clinically significant

distress or impairment in social, occupational, or other important areas of

functioning128 It seems that none of the common TCM diagnostic patterns for

insomnia mentioned about sleep disturbance associated with substances use We

concluded that none of the TCM syndrome patterns was compatible with the DSM-IV

substance-induced sleep disorder – insomnia type

Insomnia related to another mental disorder – anxiety disorders

The diagnostic criteria for insomnia related to another mental disorder – anxiety

disorders from DSM-IV 128 are basically the same as those for primary insomnia, but