Case Study: An Integrative Approach to Chronic Insomnia

This case study of insomnia is a real-life example of how Chinese Medicine is combined with modern Western medicine to create the best outcome for our patients.  This approach is called integrative medicine because it combines traditional holistic medicine with the science of Western allopathic medicine.

Insomnia is generally defined as an inability to fall asleep, stay asleep, or a combination of both. Chronic insomnia is difficulty sleeping for a month or longer. Insomnia afflicts up to 15% of the world’s population. Insomnia occurs when the biological drivers of sleep, circadian rhythms and homeostasis, are disrupted by emotional upset and chronic stress.

This letter is an example of how we coordinate care with a patient’s primary doctor:

Dear Primary Care Physician,
I have a patient suffering from chronic insomnia and would like your assistance with this case.

Case Summary:
The patient is a 32-year-old male with a chief complaint of restless sleep.  The history of present illness is insomnia difficulty falling asleep and staying asleep during the last six weeks. Sleep improves with daily exercise, is exacerbated by stress, crying baby, too much computer screen time. No night sweats, but sense of heat. Patient goes to bed at 11pm and is restless until 1-2am. He wakes 1x to urinate, usually between 4-5am. Vital signs are pulse 64 bpm, BP 118/68, 13 breaths per minute, body temp: 98.8 degrees F.

Based on the patient’s symptoms and tongue and pulse presentation, the TCM diagnosis is Heart and Kidney Yin Deficiency insomnia.

Evidence-Based Approach:
In a review study conducted by O’Brien & Weber (2016), acupuncture was found to regulate “various neurotransmitters and hormones, such as endorphins, serotonin, norepinephrine, adrenocorticotrophic hormone, cortisol, acetylcholine, melatonin, substance P, gamma-aminobutyric acid, and nitric oxide, known to be involved in sleep regulation. Acupuncture can also regulate higher cortical function, the HPA axis, and somato-visceral reflexes.”

Treatment:
The patient has agreed to receive a 60-minute Chinese Medicine treatment two times a week for four weeks. Reassessment will occur at the sixth appointment. Progress is tracked with the Measure Yourself Medical Outcome Profile (MYMOP) questionnaire. The patient completed the initial MYMOP prior to the first acupuncture treatment and will fill out a follow-up MYMOP questionnaire prior to the first appointment every week. An initial acupuncture point protocol was:

• N-HN-54 an mian (peaceful sleep)
• Bilateral KD-6 zhao hai (shining sea)
• Bilateral HT-7 shen men (spirit gate)
• Bilateral SP-6 san yin jiao (3 yin intersection)

Acupuncture needles were retained for 25 minutes while the patient was lying supine in a quiet, darkened room.

The patient received the traditional Chinese herbal formula Tian Wang Bu Xin Dan (Ginseng and Zizyphus formula) with instructions to drink three cups per day in-between meals for four weeks.

​The patient is advised to avoid caffeine and alcohol, exercise in the morning (so as to not interfere with sleep in the evening), avoid spicy and greasy foods, drink water throughout the day and cease consumption by 8pm at night, and discontinue use of all electronic devices at least 30 minutes prior to bedtime.

Expected Outcomes/Prognosis:
Prior to his first acupuncture treatment, the patient identified insomnia with a MYMOP score of “6 – as bad as it can be”.  At his third appointment, he reported better sleep and a lower MYMOP score of “3”.  I expect him to obtain more high-quality sleep within the next two weeks of treatment and report another reduced MYMOP score.

​Referrals:
Please order a CBC differential lab test and Comprehensive Metabolic Panel (CMP) for this patient and contact me with the results.

​I appreciate your willingness to share in the care of this patient.

​Sincerely,
Michelle Wendt, L.Ac. DACM, Dipl. OM