Medical history collection

Sleep condition

Ask the patient in detail about the time it takes to fall asleep, such as whether it is difficult to fall asleep (usually referring to being unable to fall asleep after more than 30 minutes) or whether it is difficult to maintain sleep (waking up easily at night and having difficulty falling asleep again after waking up). Understand the depth of sleep, whether there are many dreams, light sleep, and early awakening situations, such as waking up 1-2 hours earlier than the normal wake-up time or even earlier and being unable to fall back asleep. At the same time, count the frequency of insomnia each week, whether it occurs occasionally (1-2 times per week) or frequently (3 times or more per week).

Accompanying symptoms

Observe whether there are any emotional problems, such as anxiety, depression, irritability and anger, etc. Anxiety may manifest as excessive worry about future events and restlessness. Depression may be accompanied by symptoms such as low mood and reduced interest. Ask about digestive system symptoms, such as loss of appetite, abdominal distension, diarrhea or constipation, etc. It is also necessary to pay attention to whether there are physical symptoms such as headache, dizziness, palpitations and chest tightness, as these symptoms may interact with insomnia.

Living habits

Find out whether the patient’s daily routine is regular and whether they often stay up late or reverse their day and night. Ask about your eating habits. Do you like spicy, greasy, and stimulating foods, as well as stimulating beverages like coffee and strong tea? These foods and beverages may affect your sleep. Understand your exercise situation, whether you lack exercise or the timing of your exercise is inappropriate (such as intense exercise before going to bed).

Previous medical history

Find out whether the patient has chronic diseases such as hypertension, diabetes, and heart disease. These diseases themselves and their treatment drugs may affect sleep. Ask if there is a history of mental illness, such as depression, anxiety disorder, schizophrenia, etc. Mental illness is often associated with insomnia. It is also necessary to know whether there is a history of trauma or surgery, as well as whether certain medications have been taken for a long time, such as hormone drugs and antidepressants, etc. These factors may all affect sleep.

Inducing factors

Explore the causes of insomnia to see if it is triggered by recent high work pressure, life events (such as the death of a loved one, unemployment, marital problems, etc.), or environmental changes (such as moving house, business trips, noisy sleeping environment, etc.). Understanding these triggering factors is helpful for determining the type of insomnia and formulating treatment plans.

Physical examination

General inspection

Measure the patient’s vital signs, including body temperature, pulse, respiration, blood pressure, etc., and observe whether there are any abnormalities. Examine the patient’s mental state, such as complexion, consciousness, and expression, to determine if there are any signs of listlessness, anxiety, depression, etc.

Neurological examination

Examine the patient’s state of consciousness, orientation, memory, calculation ability and other cognitive functions, and assess whether the brain function is normal. Check motor functions such as muscle strength, muscle tone, and tendon reflexes, as well as sensory functions, to rule out insomnia caused by neurological diseases.

Other system checks

Corresponding systematic examinations should be conducted based on the patient’s accompanying symptoms. If symptoms such as palpitations and chest tightness occur, cardiac auscultation and electrocardiogram examinations can be conducted. If there are symptoms of the digestive system, abdominal palpation, auscultation and other tests can be performed.

Auxiliary examination

Polysomnography (PSG

This is the “gold standard” for diagnosing sleep disorders. By connecting multiple electrodes to the patient’s body, various physiological indicators such as electroencephalogram (EEG), electrocardiogram (ECG), electromyogram (EMG), electrocardiogram, respiratory airflow, and blood oxygen saturation during sleep are recorded. It can accurately determine the patient’s sleep structure, such as the latency to fall asleep, the proportion of time in each sleep period, the number of awakenings, etc. It can also detect whether there are sleep breathing disorders such as sleep apnea and hypopnea, as well as other sleep-related diseases such as periodic limb movement disorders.

Psychological assessment

Professional psychological assessment scales, such as the Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), and Pittsburgh Sleep Quality Index (PSQI), are used to quantitatively evaluate the psychological state and sleep quality of patients. HAMA and HAMD can help determine whether patients have emotional problems such as anxiety and depression and their severity. PSQI can comprehensively assess a patient’s sleep quality, time to fall asleep, sleep duration, sleep efficiency, sleep disorders, use of hypnotic drugs, and daytime functional disorders, among other aspects.

Laboratory inspection

According to the specific condition of the patient, blood routine tests, biochemical tests (such as liver and kidney function, blood sugar, blood lipid, etc.), thyroid function tests, etc. are conducted. A blood routine test can help determine whether a patient has any conditions such as infection or anemia. Biochemical tests can assess a patient’s liver and kidney functions as well as their blood sugar and lipid metabolism. Thyroid function tests can rule out insomnia caused by endocrine diseases such as hyperthyroidism or hypothyroidism.

Syndrome differentiation and typing

Deficiency of both heart and spleen type

Patients often present with frequent dreams and easy awakening, palpitations, forgetfulness, fatigue, poor appetite, dizziness, pale complexion, pale tongue with thin coating, and weak and fine pulse. This is because the heart governs blood circulation and the spleen governs transformation and transportation. When both the heart and the spleen are deficient, the generation of qi and blood is insufficient, and the heart spirit is deprived of nourishment, which leads to insomnia.

Liver depression with internal heat type

Patients often have difficulty falling asleep, frequent dreams and light sleep, irritability and anger, dizziness and head distension, red eyes and tinnitus, dry and bitter mouth, loss of appetite, constipation with red urine, red tongue with yellow coating, and taut and rapid pulse. The liver governs the free flow of emotions. When emotions are not fulfilled, liver depression turns into fire, which disturbs the mind and subsequently leads to insomnia.

Phlegm-heat internal disturbance type

Patients often experience restlessness during sleep, irritability, chest tightness, epigastric distension, bitter taste in the mouth with excessive phlegm, dizziness, red tongue with yellow and greasy coating, and slippery and rapid pulse. Internal accumulation of phlegm-heat disturbs the mind, affecting sleep.

Yin deficiency with hyperactivity of fire type

Most patients have symptoms such as restlessness, insomnia, palpitations, dizziness, tinnitus, forgetfulness, lower back pain, nocturnal discharge, hot flushes in the palms, soles and chest, dry mouth with little saliva, red tongue with little coating, and fine and rapid pulse. Insufficiency of kidney Yin, unable to nourish the heart, leads to excessive heart fire and disharmony between the heart and the kidney, resulting in insomnia.

Heart and gallbladder qi deficiency type

Patients often present with symptoms such as restlessness and insomnia, being easily startled by events, being constantly on guard, timidity and palpitations, accompanied by shortness of breath, spontaneous sweating, fatigue and weakness, pale tongue, and taut and fine pulse. Insomnia occurs when the heart and gallbladder qi are weak and the soul is restless.

Diagnostic conclusion

Based on the results of comprehensive medical history collection, physical examination, auxiliary examinations and syndrome differentiation and typing, a clear diagnosis is given. For instance, if a patient has symptoms such as difficulty falling asleep, frequent dreams and easy awakening, polysomnography shows sleep structure disorder, and psychological assessment indicates the presence of anxiety, and the diagnosis is liver depression with internal heat, then it can be diagnosed as “liver depression with internal heat insomnia”. At the same time, other diseases that may cause insomnia should be ruled out, such as physical illnesses (such as pain, breathing difficulties, etc.), mental illnesses (such as depression, anxiety disorders, etc.), and drug factors (such as caffeine, certain antipsychotic drugs, etc.), to ensure the accuracy of the diagnosis.