Do you also experience nights like this? Utterly exhausted, yet tossing and turning, unable to fall asleep; finally managing to sleep, only to have vivid dreams and wake easily startled... For this kind of stubborn insomnia, what effective treatments does Traditional Chinese Medicine (TCM) offer?
What causes insomnia with vivid dreams and easy startling?
Dr. Que Poh Yuen Albert, a TCM expert at Gong Fang Tang TCM Clinic in Singapore, explains that the causes of long-term insomnia, restless sleep, and easy startling are diverse. However, in clinical practice, one type is particularly common and often overlooked: Liver Qi Stagnation Transforming into Fire, Phlegm-Heat Harassing the Heart, coupled with Unsettled Heart-Mind (Shen).
Liver Stagnation Transforming into Fire is the starting point: Long-term high stress, emotional depression, or anxiety lead to liver qi stagnation. Stagnated qi, over time, transforms into fire, forming "liver fire." This "fire" ascends to disturb the heart-mind (shen).
Internal Generation of Phlegm-Heat is the accomplice: Liver stagnation also affects spleen transportation and transformation (liver wood overacting on spleen earth). Spleen deficiency then generates dampness, which congeals into phlegm. Liver fire combines with phlegm-dampness, forming the more troublesome "phlegm-heat." Phlegm-heat, being sticky and turbid in nature, most easily clouds the upper orifices and disturbs the heart-mind.
Unsettled Heart-Mind (Shen) is the key: The heart governs the spirit/mind (shen), acting as the "commander-in-chief" of sleep. When the "pathogenic factors" of liver fire and phlegm-heat continuously attack upward and disturb the heart-mind, the shen cannot settle peacefully. This manifests as:
Difficulty falling asleep: Thoughts race uncontrollably in the mind.
Profuse, vivid dreaming: Dreams are bizarre, tense, or even nightmarish.
Light sleep, easily startled: Waking up startled by slight noises or for no apparent reason, accompanied by heart palpitations.
Difficulty falling back asleep after waking: Feeling exceptionally clear-headed after waking startled, making it hard to return to sleep.
Often accompanied by symptoms like chest and rib-side distension, bitter taste and dry mouth, dizziness and head distension, irritability and easy anger, dry stools or sticky stools that are difficult to pass.
How does TCM treat stubborn insomnia with vivid dreams and easy startling?
Dr. Que Poh Yuen Albert emphasizes that for this type of insomnia, relying solely on sleeping pills is often ineffective or leads to dependency, as it fails to address the core pathological mechanisms of liver stagnation, phlegm-heat, and unsettled shen. The classic TCM formula Bupleurum plus Dragon Bone and Oyster Shell Decoction (Chai Hu Jia Long Gu Mu Li Tang) is particularly suitable. It harmonizes yin and yang, heavily settles and calms the spirit, making it an excellent formula for treating stubborn insomnia caused by "Shaoyang disharmony, phlegm-heat harassing the heart, and floating/frenetic heart-mind."
Bupleurum plus Dragon Bone and Oyster Shell Decoction consists of Bupleurum (Chai Hu), Dragon Bone (Long Gu), Oyster Shell (Mu Li), Scutellaria (Huang Qin), Pinellia (Ban Xia), Poria (Fu Ling), Ginseng (Ren Shen), Cinnamon Twig (Gui Zhi), Rhubarb (Da Huang), Fresh Ginger (Sheng Jiang), and Jujube (Da Zao).
Dr. Que Poh Yuen Albert analyzes the essence of the formula composition:
Soothes the Liver, Resolves Stagnation, Clears Fire: Bupleurum (Chai Hu) and Scutellaria (Huang Qin) act as the sovereign herbs (Jun). They course and resolve stagnant liver qi and clear internally generated stagnant heat/liver fire, addressing the problem at its source.
Heavily Settles the Spirit, Calms Fright: Dragon Bone (Long Gu) and Oyster Shell (Mu Li) are the soul of the formula! They are heavy in substance and sinking in nature, possessing powerful actions to calm fright, settle the spirit, and anchor floating yang and stabilize the will. They act like "stabilizing pillars" to firmly settle the floating, restless heart-mind (shen), effectively resolving easy startling, palpitations, and vivid dreams. Dr. Qiu often increases the dosage of these two herbs in clinical practice (commonly 30g or more each, decocted first) to enhance their heavy settling power.
Transforms Phlegm, Clears Heat, Harmonizes the Stomach: Pinellia (Ban Xia) and Poria (Fu Ling) dry dampness, transform phlegm, regulate qi, and harmonize the stomach. Rhubarb (Da Huang) (usually added later or used lightly) unblocks the fu organs and drains heat, providing an outlet for the phlegm-heat pathogen.
Promotes Yin-Yang Communication, Supports Upright Qi: Cinnamon Twig (Gui Zhi) frees yang. Fresh Ginger (Sheng Jiang) and Jujube (Da Zao) harmonize the nutritive and protective aspects (ying-wei) and support the spleen and stomach. Ginseng (Ren Shen) (or Codonopsis/Dang Shen as a substitute) boosts qi and supports upright qi, preventing the heavy settling herbs from damaging healthy qi.
The whole formula works synergistically: It courses liver qi, clears liver fire, transforms phlegm-heat, settles the heart-mind (shen), unblocks the fu organs, and harmonizes yin and yang. It directly targets the core pathology of liver stagnation transforming into fire and phlegm-heat harassing the heart leading to insomnia with vivid dreams and restless, easily startled sleep, treating both the root and the branch.
Modifications and Applications:
Given the local hot and humid climate and fast-paced lifestyle, liver stagnation with phlegm-heat type insomnia is especially common here, making this formula widely applicable.
Emphasis on precise pattern differentiation: Patients must exhibit typical signs of liver stagnation transforming into fire (bitter taste, irritability, rib-side distension) and phlegm-heat harassing the heart (vivid dreams, easy startling, chest oppression, greasy tongue coating).
Flexible modifications: Add Bamboo Shavings (Zhu Ru) and Arisaema cum Bile (Dan Nan Xing) for severe phlegm-heat; add Magnetite (Ci Shi) and Mother-of-Pearl (Zhen Zhu Mu) for severe fright and palpitations; add Lily Bulb (Bai He) and Ophiopogon (Mai Dong) for significant yin deficiency; add Salvia (Dan Shen) and Peach Kernel (Tao Ren) for signs of blood stasis.
Case Study
Patient: Mr. Chen, 42 years old.
Chief Complaint: Stubborn insomnia for over 3 years, worsening in the last 6 months. Difficulty falling asleep nightly (taking 2-3 hours), vivid nightmares after sleep, easily startled (3-4 times per night), waking with heart palpitations making it hard to fall back asleep. Total sleep less than 3 hours per night. Accompanied by severe anxiety, irritability and easy anger, bitter and dry mouth, chest oppression, dizziness, dry stools. Long-term dependence on sleeping pills with diminishing effect and significant side effects.
Initial Consultation: Tongue body red with thick, yellow, greasy coating. Pulse wiry, slippery, rapid.
Pattern Differentiation: Liver Qi Stagnation Transforming into Fire, Phlegm-Heat Harassing Internally, Heart-Mind Unsettled.
Treatment Principle: Soothe the Liver, Clear Heat, Transform Phlegm, Calm the Spirit, Heavily Settle and Stabilize the Will.
Prescription: Modified Bupleurum plus Dragon Bone and Oyster Shell Decoction.
Herbs: Bupleurum (Chai Hu) 15g, Scutellaria (Huang Qin) 12g, Pinellia (Ban Xia) 12g, Poria (Fu Ling) 20g, Raw Dragon Bone (Sheng Long Gu) 30g (decocted first), Raw Oyster Shell (Sheng Mu Li) 30g (decocted first), Cinnamon Twig (Gui Zhi) 9g, Prepared Rhubarb (Zhi Da Huang) 6g (added later), Mother-of-Pearl (Zhen Zhu Mu) 25g (decocted first), Bamboo Shavings (Dan Zhu Ru) 10g, Stir-fried Gardenia (Chao Zhi Zi) 9g, Honey-fried Licorice (Zhi Gan Cao) 6g. Fresh Ginger (Sheng Jiang) 3 slices, Jujube (Da Zao) 5 pieces.
Second Consultation (after 7 doses): Time to fall asleep shortened to within 1 hour, nightmares reduced, night waking frequency reduced to 1-2 times, feelings of anxiety and irritability lessened, stools became smooth. Tongue coating thinner. Continued with the same formula for another 14 doses.
Result: Sleep continued to improve, achieving 5-6 hours of restful sleep per night, nightmares essentially disappeared, waking startled occurred very rarely (1-2 times per week), mental and physical energy significantly recovered, mood stabilized.
