Research and discussion on the insomnia with depression and anxiety

: According to traditional Chinese medicine, insomnia with depression and anxiety belongs to the category of "sleeplessness and depression disease" in Chinese medicine., from the analysis of disease location, both are closely related to heart and liver, and from the analysis of etiology, the onset of both is closely related to emotional and mental disorders, so insomnia with depression and anxiety is treated from the perspective of the same treatment of heart and liver.


Introduction
Chinese medicine calls insomnia "sleeplessness", which is a type of disease characterized by frequent failure to obtain normal sleep, the lighter the difficulty in falling asleep, or sleep but not sound, waking up at times, or not being able to sleep again after waking up, the heavier the sleeplessness [1] [2] In recent years, with the increasing social competition and life pressure, the number of patients with insomnia accompanied by depression and anxiety is increasing day by day, and the prevalence is rising year by year.Through literature study and clinical observation and practice, we found that the treatment of sleeplessness from the heart and liver can achieve good results.Now we are going to discuss the method of treating sleeplessness from heart and liver theory.

Understanding of the etiology and pathogenesis of Chinese medicine 2.1 Understanding of insomnia in Chinese medicine
In Chinese medical texts, insomnia is mostly described in terms of the patient's clinical manifestations, such as "not sleeping" "eyes not closing" and "not being able to sleep", etc.Among them, "Nangjing" is the first one to appear.The earliest description of "sleeplessness" is found in [3].The Yellow Emperor's Classic of Internal Medicine was the first to elaborate on the theory of insomnia, believing that the imbalance of yin and yang in the human body caused by evil qi visiting the internal organs leads to insomnia.According to the ancestral medicine, the causes of insomnia mainly include poor diet, internal injury of emotion and will, disorders of labor and relaxation, deficiency of endowment, and deficiency of the body after a long illness.There are various theories on the pathogenesis of insomnia, including the theory of internal organs, qi and blood, yin and yang, and the five gods, etc.The main identification of internal organs is that insomnia is closely related to the heart and liver, and involves the lungs, spleen and kidneys [4] .

Chinese medicine's understanding of depression and anxiety
There is no clear name for depression and anxiety in ancient Chinese literature, but according to the available records, it can be classified as "depression evidence" in Chinese medicine.[5] , "Classics" corresponds the depression of the five movements to the depression of the five organs, and believes that all five organs may have depression evidence.Zhu Danxi pioneered the "six depressions", in which six pathological factors: qi, blood, phlegm, fire, dampness, and food can all cause depression, with qi depression being the first of the six depressions, and depression being the cause of many other diseases.In the Ming Dynasty, Zhang Jiebin, based on his predecessors, categorized depression as anger depression, thought depression and melancholy depression, linking depression to emotional disorders, opening up another line of thought.After exploring and summarizing the findings of successive generations of physicians, it is believed that emotional factors are an important cause of depression, and the pathogenesis is most closely related to the heart and liver, with the pathogenesis being qi stagnation and dysfunction of the internal organs.[6]

Chinese medicine understanding of insomnia with depression and anxiety
In ancient times, medical practitioners had a certain understanding that insomnia could be accompanied by anxiety and depression.According to the Nei Jing, disorders of emotion and will can lead to the disruption of the balance of yin and yang and the rebellion of qi and blood in the internal organs, which can lead to insomnia and depression.[7]Insomnia and depression are both closely related to the heart and liver.Chinese medicine believes that the heart is the master of the mind and the liver is the master of the emotions, and the emotions will have a certain interactive effect on the heart.

Heart and liver damage is the etiology of insomnia with depression and anxiety
Huang YuanYu proposed the theory of "One Qi Circulation", which is "the left path of wood and fire rising, the right path of gold and water converging and descending, and the middle jiao and earth qi mediating", in which one qi is the middle qi.The turbid Qi part rotates to the right and becomes the stern and sluggish Lung Gold Qi, which continues to descend and becomes the cold Kidney Water Qi, thus forming a complete Qi flow in the body [8].In other words, under the rotating effect of the spleen earth, the clear yang rises and the cloudy yin descends, and the rise and fall of yin and yang gives rise to the four signs of (lung) gold, (liver) wood, (heart) water and (kidney) fire.The combination of the four signs of earth is the so-called five elements [9].The theory of "one qi flow" emphasizes the flow of qi in the human body, the normal functioning of the qi of the internal organs and the overall balance of the human body."On the other hand, it also complements the theory of the internal organs, which looks at diseases from a different perspective and restores the body's circumference by adjusting the qi flow.If various factors affect a certain part of the operation of "one qi flow", the body will produce disease.Based on this, the etiology of sleeplessness is mainly divided into disorders of the middle earth (spleen and stomach disorder), left rotation (heart and liver damage), right rotation (kidney damage), poor circulation, and lack of connection between yin and yang [10] .
Yin rises and falls to transform Yang, Yang rises on the left, then the liver, rises on the top, then the heart, left dysfunction is nothing but the two ends of the deficiency.The deficiency is due to the lack of qi and blood of liver wood, which is unable to produce heart qi, resulting in the lack of qi and blood of heart, followed by insomnia due to disharmony in the function of heart and mind; the reality is that the rise and development is too much, liver wood qi stagnation, depression and fire, evil fire directly disturbs the heart and mind, heart fire and liver wood rise and development is too much, resulting in heart fire, restlessness and sleeplessness [11] .With the further exploration of modern medical doctors, the application of the theory of Qi flow in insomnia has gradually increased, and modern medical doctors pay more attention to the earth Qi mediation of the middle Jiao, and with the fast-paced pace of work and the increase in the pressure of life in today's society, a considerable number of patients with insomnia accompanied by depression and anxiety are injured by the seven emotions at the beginning of the disease, and the Qi is not running smoothly, beyond the scope of the liver's own regulation [12] , the liver's drainage is abnormal and the Qi is stagnant, and for a long time it turns into fire and heat.In addition to tossing and turning, difficult to sleep, dreamy and easy to wake up, and other manifestations of mental restlessness; and mental depression, emotional restlessness, or chest fullness, dullness and pain in the ribs, or anxiety and heat, impatience and irritability, dizziness, sadness and desire to cry, negative anxiety, and other manifestations of liver depression and heart fire on inflammation.This is a co-morbidity of the heart and liver [13], and the related arguments have been verified by experimental and clinical studies [14] [15].According to the clinical practice and the theory of the circumferential flow of Qi, the group believes that the pathogenesis of insomnia with depression and anxiety is the imbalance of the left rotation of Qi elevation, that is, the heart and liver are damaged.In other words, the evil disturbs the heart and mind, the heart and mind is disturbed, and the seven emotions are injured, the liver is depressed and heat is turned into heat, the heart fire is inflamed, the ascending and descending of the liver wood is too much, the liver wood is stagnant, the heart fire is inflamed and the liver wood is ascending and descending too much, resulting in the heart fire is vigorous, the mind is disturbed, the left rotation is dysfunctional, the ascending and descending of the left qi is too much, the phase fire is delusional, the transformation of yin and yang ascending and descending is blocked, and the yin and yang is dysfunctional.[16] Therefore, insomnia with depression and anxiety should focus on regulating the qi flow, treating wood and fire together, and giving qi-regulating and tranquilizing soup plus or minus.

Qi-regulating and tranquilizing soup
It is composed of more than 10 herbs, including Chai Hu, Ziziphus nourishing the heart and tranquilizing the mind, together with Radix et Rhizoma Pinelliae, Hesperidin, Oyster, Radix Angelicae Sinensis, Radix et Rhizoma Cinnamomi and Radix Paeoniae Alba.Chuanxiong is warm in nature and moves Qi to unblock the Liver and warm the Liver Qi, making the left path wood fire; Scutellaria baicalensis can clear the heat of the Liver Qi that is not unblocked, preventing the Liver depression from turning into fire and violating the Spleen and Earth; Gui Zhi penetrates the meridians and helps the Qi to run, with Gui Zhi to harmonize the Ying and Wei, Bai Shao is salty in taste, Long Bone Oyster is salty and heavy in quality, and can help the Qi of the Heart Fire to dive down and calm the mind, Yu Jin and Hehuan Bark enter the Heart and Liver meridians, clearing fire and nourishing the Heart, relieving depression and calming the mind, with Bai Shao The combination of multiple drugs makes the liver wood rise and the heart fire dive down, so that the path of the left wood fire rises and falls smoothly and the transformation of yin and yang rises and falls returns to normal, with the flow of Qi flowing around as usual and sleep.

Summary
Although a variety of clinical evidence has provided a multi-faceted and multi-angle theoretical thinking, the complexity of the disease mechanism has also made clinical evidence identification difficult.In recent years, with the extensive application and deep excavation of traditional medicine, modern medical practitioners have discovered that Mr. Huang Yuan-yu's theory of "one qi flowing around", which combines the theory of zangxiang and the theory of five elements, integrates the internal organs, ying and health, qi and blood identification into the running changes of one qi of the internal organs and qi, thus summarizing the essence of Chinese medicine theory as the changes of one qi [17] , through By studying Huang Yuan-young's theory of one qi flow, combined with longterm clinical practice experience, we believe that insomnia with depression and anxiety is caused by the evil staying in the viscera and the disturbance of the heart and mind, coupled with the loss of drainage of the liver and the long depression and heat disturbing the heart and mind, resulting in the imbalance of the left rotation of the qi flow and the imbalance of yin and yang.Therefore, we propose to treat insomnia with depression and anxiety from the perspective of "wood and fire together", which provides new ideas for the identification of insomnia with depression and anxiety.