This Journal article originally was titled All Tuckered Out- Approaches to the treatment of tiredness with Chinese medicine. Will Maclean is an internationally recognised author of acupuncture and Chinese herbal medicine texts and is a sought after lecturer and speaker.
Tiredness is one of the most common complaints in the modern Chinese medicine clinic. Tiredness can mean different things to different people, from a lack of physical or mental energy, a lack of motivation or get up and go, to excessive sleepiness or a devastating inability to perform even the simplest of tasks. Tiredness can be both acute and fleeting, arising as the result of some relatively short term illness, a change in routine, diet, work habits or sleep patterns, or more commonly in the Chinese medicine clinic, chronic, and in some cases debilitating. Even though tiredness and fatigue can be a part of almost any disharmony, there are some patterns that consistently produce a significant element of tiredness, or tiredness as a major feature. The aim of this article is to offer an overview of these common patterns of tiredness. Each pattern is discussed as a discrete entity, but of course in actual practice, patients, especially the chronically ill, tend to have multiple and overlapping patterns. A sound understanding of the individual components, however, enables a flexible therapeutic solution.
Tiredness from a western medicine point of view is often one of those ‘heart sink’ symptoms. Unless there is a demonstrable pathology, such as thyroid deficiency, exposure to Epstein Barr virus, elevated blood sugar or anemia, the qualitative experience of the tiredness is left unexplored, and the patient undiagnosed, or worse, consigned to the category of ‘depression’, or psychological disorder, or worse, as a malingerer.
Chinese medicine, with its subtle understanding of the rhythms and tides of qi and blood, is able to tease out the precise experience of the tiredness, how it feels to the patient. When does it occur? Where is the tiredness experienced? Is it physical, mental or both? What are the main aggravating and ameliorating influences? Is there heaviness of the body and spirit or aching in the limbs? Is there sleepiness after eating? Is there a general sense of directionlessness and depression? Answers to these questions builds a picture of the quality and distribution of the individuals qi and blood, and the presence or otherwise of any influential pathogens.
It is important to clearly establish what people mean by tiredness, and patient expectations of what constitutes normal energy can vary considerably. We need to define what a normal level of energy is for each individual. Are they unable to perform tasks they could do easily before? Are their expectations of what energy levels they should have realistic? Is the tiredness normal for the situation the patient is in? Does she or he have a new baby, work night shift, suffer from insomnia or have noisy neighbors?
It is not uncommon in today’s driven world for people to expect to be able to work all day, go to the gym or party in the evening, sleep for a few hours and do it all again the next day. Of course, our resources are finite, and the simple economics of energy intake and output need to be clearly explained.
Why do people feel tired?
There are two basic reasons according to Chinese medicine. Either they have insufficient quantities of one or more of the fundamental physiological substrates (qi, blood, yin, yang), or the distribution of these substrates is impaired in some way. If the distribution of qi and blood is blocked in some way, there must be a pathogen or a pathological accumulation of some sort blocking it. In practice, a combination of insufficient qi, blood, yin or yang and some sort of pathological obstruction (dampness, phlegm, qi or blood stasis etc.) is common.
Differentiating different types of tiredness
There are several key features that can help identify the nature of the tiredness. Tiredness upon waking or following periods of rest generally indicates a repletion pattern of some type, typically qi stagnation, phlegm damp accumulation or damp heat. During rest, circulation slows down and yin pathogens (dampness, phlegm etc.) tend to congeal further. Their presence blocks qi and blood distribution.
Conversely, does the patient feel better following a good walk or some other activity? This tends to indicate a repletion pattern, as stimulating circulation and increasing heart rate can shift accumulations and activate qi.
Tiredness that is alleviated with a good sleep or a rest is usually of a deficiency type, as rest enables the body to replenish some of the deficit. It is easily spent in activity however, and patients will feel worse following exertion and at the end of the day.
Tiredness following eating points to Spleen deficiency or dampness. Tiredness with an emotional component points to the Liver. Tiredness aggravated by cold weather implicates the Kidneys.
Following are a selection of some of the more common simple patterns of tiredness.
Liver qi stagnation
The tiredness and fatigue associated with Liver qi stagnation is characterized by poor distribution of qi and blood. The main features are intermittent tiredness and fatigue, lack of motivation and the feelings of ‘I can’t be bothered’. The intermittent nature of the tiredness is an important clue. They have days or periods when they feel well, then will experience a period of tiredness, often associated with increasing stress levels or some emotional turmoil. This contrasts with the tiredness of the deficiency patterns, which will tend to be there, at least in the background, all the time and get worse predictably with expenditure of energy.
Patients with qi stagnation typically wake feeling tired and have difficulty getting out of bed, but improve as the day goes on. They feel better following exercise or other physical activity, and usually have sufficient energy for activities that are interesting to them. When in periods of increasing tiredness they tend to become grumpy, irritable and depressed, and muscular stiffness, tightness and pain, especially around the neck, shoulders, mid scapular and mid thoracic region will be exacerbated. They may also become constipated. The tiredness may be exacerbated before a menstrual period, a work deadline or other stressful event.
Because qi stagnation is essentially a physiological response to ones environment, the long term solution is to alter the environment or the individuals responses to it. Changing the environment (changing jobs, relationships, families, finances etc.) is often easier said than done, so the most satisfactory approach is to gradually modify the responses, in a way physiologically retraining the individual to a new way of reacting to stimuli. The experience of Chinese medicine practitioners is that such modifications can be made with persistent treatment, and Liver coursing, qi regulating formulae are a valuable addition to the therapeutic armoury. There are numerous approaches, depending on the additional features on display. For qi stagnation complicated by Spleen and blood deficiency, a very common pathological triad in women, the best formula is Xiao Yao Wan (Free and Easy Wanderer Teapills). For uncomplicated cases, as often occurs in men, Chai Hu Shu Gan Wan (Bupleurum Soothe Liver Teapills) is effective.
Chronic Liver qi stagnation will often be complicated by blood stasis. The tiredness of blood stasis frequently overflows into quite serious mood disorders and may be indistinguishable from endogenous depression. Serious lack of motivation and an attitude of ‘stuckness’ are common. In severe cases a pervading sense of hopelessness and a ‘why bother’ attitude prevails. They will feel somewhat better after exercise, but not as much as with qi stagnation, and worse with prolonged inactivity. Other features that point to blood stagnation are vascular abnormalities on the face, over the liver and lower extremities (varicosities, spider nevii, purple congested veins around the medial malleolus and medial knees), skin discoloration, pressure pain on the acupoint Stomach 27 (left side), and a purple of blotchy tongue with dark and distended sublingual veins. These patients often suffer chronic sleep disturbances that compound their sense of fatigue.
The treatment aims to gradually improve the systemic movement of qi and blood. The best formula to achieve this is Xue Fu Zhu Yu Wan (Stasis in the Mansion of Blood Teapills), an excellent broad acting general blood stasis dispersing agent. Treatment is lengthy, with a minimum of 6-9 months required to effect change, and often longer for a solid result.
Phlegm is a dense pathogen and one that can significantly obstruct the distribution of qi and blood. In general phlegm is a chronic problem, and may be associated with the diet (both the volume of food consumed and the types of food are influential in generating phlegm) or with an inherited tendency to phlegm. Phlegm tends to produce a variable tiredness, increasing as the phlegm congeals (with inactivity, large volumes of food, dairy products and rich or oily foods), and decreasing as the phlegm is mobilized (by exercise, decrease in food intake, drying or pungent foods). Patients with phlegm patterns tend to feel ‘weighed down’ and may complain of heaviness of both the spirit and body. They may be overweight, and often feel depressed, foggy headed, unable to think clearly or concentrate. They may exhibit physical signs of phlegm, such as sinus congestion, productive cough, throat clearing or even benign rubbery masses such as subcutaneous lipomas, breast cysts or ganglions. They often suffer from relatively severe dizziness or vertigo, which is initiated or exacerbated by strong piercing odors such as perfume or gasoline. Any gastrointestinal symptoms present, such as nausea or heartburn are also aggravated by strong smells. The reason for this is that powerful and volatile substances with a piercing fragrance are very dispersing to accumulated yin pathogens (hence the use of smelling salts in syncope) and can mobilize phlegm and dampness. In Chinese medicine we can utilize this principle in a controlled and therapeutic fashion to gradually break up and disperse the phlegm without overdoing it and causing symptoms. The typical tongue of a phlegm sufferer is swollen, and may or may not have a thick coat.
There are a number of solutions depending on the precise location and genesis of the phlegm. The most useful and broad acting phlegm transforming formula, and the one from which all others are built is Er Chen Wan. This formula is suitable for all phlegm patterns, and in combination with appropriate dietary modifications, will over time dry and transform phlegm. If the phlegm has been produced by Spleen deficiency, treatment should both strengthen the Spleen and transform phlegm. Liu Jun Zi Tang (Six Gentlemen Teapills) or Xiang Sha Liu Jun Zi Tang (Six Gentlemen Plus Teapills) answers nicely.
If the phlegm is concentrated in the head causing tiredness accompanied by serious dizziness or vertigo, tinnitus, nausea and vomiting, the solution is to disperse the phlegm with Ban Xia Bai Zhu Tian Ma Tang.
Even though in general phlegm type tiredness tend to be a long term problem, it may occur as a more acute condition, appearing in the aftermath of an acute febrile illness. In this situation, physiological fluids are quickly cooked and congealed into phlegm heat by the heat of the battle between defensive qi and the pathogenic invader. Patients will typically present with ongoing fatigue and tiredness that has persisted even though the initial illness (typically an upper respiratory tract infection, but any substantial fever may be implicated) has resolved. They also tend to feel anxious and restless, may experience dizziness, palpitations and have difficulty sleeping. The tongue has a thick yellow coat. The solution to this lingering phlegm heat is to clear the heat and transform the phlegm with Wen Dan Wan (Rising Courage Teapills). With the correct diagnosis and treatment, this is one of those rare times when phlegm (and the symptoms associated with its presence) can be resolved quickly, usually no more than a couple of weeks.
Shao yang syndrome
This pattern is associated with the presence of a pathogen that has reached an equilibrium with the body’s immune responses. In Chinese medicine terms such lingering pathogens are said to lodge in the shao yang level, a kind of holding space between the exterior of the body (the first point of contact) and the interior (the internal organs). The process of containing a pathogen in this zone is energetically expensive, and one of the main features is tiredness and fatigue. This pattern is typical of the patient who presents days, weeks or months following a trivial infection such as the flu, an upper respiratory tract infection or gastrointestinal infection, saying ‘I have never felt well since……’. It can also follow vaccinations. In addition to the tiredness which is often the main feature, the symptoms include alternating fever and chills (although in chronic cases this is often described as ‘flu like’ feelings that occur when feeling particularly tired), dizziness, loss of appetite, bitter taste in the mouth, tightness in the muscles beneath the right rib margin and a wiry pulse. Shao yang syndrome is a remarkably common condition, and one that responds quickly to correct identification and treatment. The solution is to close the shao yang level, in effect evicting the lurking pathogen. This action, technically described as harmonizing the shao yang, can be achieved with the ancient formula Xiao Chai Hu Tang (Minor Bupleurum Teapills) , or if there is also constipation, Da Chai Hu Tang (Major Bupleurum Teapills)
Qi deficiency predominantly affects the Lungs and Spleen. These organ systems are the qi harvesting systems of the body, turning the raw materials of food and air into a form of qi the body can use. Dysfunction or weakness in either the Lungs or Spleen will lead to qi deficiency. Conversely qi deficiency in any other system, or excessive demand for qi (from overwork, insufficient nutrition etc.) will place a burden on the Lungs and Spleen and eventual weakening, The tiredness associated with Lung and Spleen qi deficiency is derived from a lack of functional energy, often complicated by accumulation of dampness (or phlegm), so the function of the various organ systems that rely on a steady supply of qi is diminished. Spending energy further depletes their already low reserves, so patients feel worse at the end of the day or after any exercise or exertion. They will also tend to feel tired or sleepy after eating, especially large or rich meals and most commonly lunch, as qi is diverted from the brain to the digestive system. They will quickly tire with mental activity, study and prolonged concentration, all of which tend to drain the Spleen further. They tend to feel significantly better with a good night sleep or after a rest. Depending on whether the Spleen or Lungs is most affected the accompanying features will vary. In all cases however, the tongue is pale and swollen, or scalloped with teethmarks.
When the Lungs are predominantly affected the tiredness takes the form of an inability to exert oneself without becoming breathless and sweating copiously. Their shoulders tend to hunch forward and breathing is shallow, and even talking can be an effort, so they tend to be quiet and speak softly.
Spleen qi deficiency is characterized by gastrointestinal weakness, loss of appetite, frequent abdominal distension and bloating and loose stools. Decreased muscle tone combined with lack of energy may cause a slumped posture, or difficulty holding the head upright. The tiredness (or sleepiness) is worse after eating and exertion.
Spleen qi deficiency is often complicated by dampness, which can modify the picture somewhat. Patients with qi deficiency and dampness will find it hard to get started in the morning, improve during the morning, then feel tired again in the afternoon. The tiredness takes on a slightly different quality when dampness is present. The dampness settles like a mist over the consciousness, so foggy headedness or difficulty in concentration is more pronounced. The lack of energy and fatigue of qi deficiency are compounded by a sense of heaviness or sluggishness in the body, which makes every activity more of an effort. They will want to lie down and sleep a lot, but will wake feeling worse. As for all qi deficiency patterns the tongue is pale and swollen with teethmarks on the edges. The difference is in the tongue coat, the thickness and greasiness of which reflects the degree of dampness
In general, qi deficiency is quite easy to remedy when sensible diet and work practices are combined with a targeted herbal therapy. Being such a common pathology, qi deficiency has many solutions, depending on the location of the deficiency and the complicating features. The basic prescription for strengthening the Lungs and Spleen and thus improving the harvesting and manufacture of qi is Si Jun Zi Tang (Four Gentlemen Teapills). This basic formula is suitable for all patterns of qi deficiency as strengthening the Lungs and Spleen will bolster qi systemically. If qi deficiency is complicated by dampness or phlegm, in which either Liu Jun Zi Tang (Six Gentlemen Teapills) or Xiang Sha Liu Jun Zi Tang (Six Gentlemen Plus Teapills) will serve. When Lung qi and defensive qi are especially weak causing susceptibility to infection, easy sweating and breathlessness, Yu Ping Feng Wan (Jade Screen Teapills) is the specific solution. When Spleen qi fails to support Heart qi and produce sufficient blood to anchor the shen (spirit), the features are tiredness, fatigue and sleepiness during the day, but with an inability to sleep soundly at night, being woken frequently with anxiety or palpitations. These patients may suffer from nervousness or panic attacks. The solution is to fortify the Spleen and Heart and calm the shen with the wonderful Gui Pi Wan (Gui Pi Teapills). With a mixture of Lung and Spleen qi deficiency, weak immunity and poor muscle tone (slumping posture, prolapses, sagging flesh) the solution is Bu Zhong Yi Qi Wan (Central Chi Teapills).
Blood deficiency usually affects the Liver and Heart, and derives from insufficient production of blood from Spleen qi deficiency or poor nutrition, inadequate replacement of blood following hemorrhage, childbirth or excessive consumption of blood. This is a very common pattern of chronic tiredness in modern mothers who return to work too soon, or who are unable to rest adequately to replenish the blood used to manufacture baby, or who breastfeed too long as milk is directly derived from blood. The tiredness is characterized by low reserve of energy, lack of vitality, feelings of apathy and increased vulnerability to the normal stresses of daily life. Every little thing becomes an effort. They feel drained and weak. Like all the deficiency patterns, blood deficiency tiredness is worse with activity and at the end of the day, and better for rest. This is complicated however by difficulty sleeping, a common feature of blood deficiency. Exhaustion during the day is replaced by a racing mind at night and a vicious cycle can be established. Patients with blood deficiency patterns will also find their tiredness worse with prolonged use of the eyes, sitting in front of a computer for long periods and following any blood loss, such as after menstruation. Postural dizziness or lightheadedness and visual disturbances or spot in the visual field are common, the skin and hair tends to be dry and the nails are weak and brittle or ridged. The tongue is thin, dry and pale.
Replenishing blood takes time and persistence, as ‘it takes 40 parts of qi to make 1 part of blood and 40 parts of blood to make 1 part of jing (essence)’. Gradual building of blood with diet, adequate protein and rest is assisted with formulas that combine Spleen strengthening with blood nourishment. These include Ba Zhen Wan (Womens Precious Teapills), Gui Pi Wan (Gui Pi Teapills) and Shi Quan Da Bu Wan (Ten Flavour Teapills).
The tiredness of yin deficiency is characterized by the dual features of tiredness or exhaustion, compounded by a sense of jitteriness, agitation and overstimulation that makes resting difficult. They will complain of being without energy or completely exhausted at the end of the day, but unable to relax or sleep. They will often describe themselves as being on edge or feeling burned out, and will appear restless and unable to settle. This is because of the general over stimulation that occurs as a result of the deficiency heat in the system. The practitioner will first note the warm dry palm upon shaking hands. These patients often suffer from, tinnitus that is worse after exertion and sex, a tendency to dry skin, throat and mouth, possible constipation and in some cases night sweats. The tongue is typically red and dry.
Kidney yin is damaged through overwork, especially while under stress, repeated late nights, shift work and insufficient sleep. Yin is also consumed by severe febrile diseases, insufficient hydration and, significantly, drug use. Stimulant drugs, such as cannabis, amphetamines, ecstasy and cocaine, seriously plunder and exhaust the yin. Inappropriate use of hot natured yang supplementing substances and herbs to increase energy levels (common in these patients), such as coffee, red ginseng and deer horn, can also damage Kidney yin. Kidney yin deficiency tiredness is common and becoming more common in younger individuals (20s to 40s), as a result of lifestyle and drug use.
The solution is to gradually rebuild Kidney yin. This is often a slow process, and must be supported by changes in lifestyle. The most important changes are more active rest and particularly sleep, a yin nourishing diet, changes to work practice and life habits. There are several variations of herbal support for Kidney yin, and these are based on the accompanying signs and symptoms. In mild cases, the famous Liu Wei Di Huang Wan (Six Flavour Teapills) or Zuo Gui Wan (Left Side Replenishing Teapills) will do the job nicely. If the patient is quite hot, with night sweats, restlessness at night, vivid dreams, flushing and a tendency to easily overheat, Zhi Bai Ba Wei Wan (Eight Flavour Rehmannia Teapills) is suitable. When insomnia, palpitations and anxiety are a feature, possible with occasional mouth ulcers, Tian Wang Bu Xin Dan (Emperors Teapills) is excellent. When the Liver is involved (dry eyes, irritability, hot temper) Qi Ju Di Huang Wan (Lycium Rehmannia Teapills) is the solution. If yin deficiency is complicated by qi stagnation, Yi Guan Jian Wan (Linking Decoction Teapills) will help.
Kidney yin can be reliably rebuilt if the therapy is maintained for sufficient time. Often 9-12 months of therapy are necessary for a satisfactory, long lasting result.
Yang deficiency tends to affect the Kidney, Spleen and Heart, each with it own specific features. However, the characteristics of the tiredness produced by insufficient yang are consistent, regardless of the organ system most affected. Yang deficiency tends to produce a sense of a deep and disabling exhaustion. Reserves of energy are very low and patients often comment that they need to carefully plan their activities as know they will only be able to do so much before collapsing. Once they have collapsed it can take days to recover sufficiently to get active again. Their exhaustion is worse in Winter, during cold snaps or if they get chilled, and following any exertion or consumption of cold natured foods. They are cold intolerant and feel cold to the touch, urinate frequently or need to get up during the night to urinate. There is an increased desire to sleep. If the Spleen is affected, they will be very sleepy or unable to stay awake after meals, the appetite is poor and there will be undigested food in the soft or loose stools. With Heart yang deficiency, the circulation is poor and they are breathless with exertion. The aim of treatment is to warm and replenish the reserves of yang. Most formulae focus on the Kidneys as the source of the body’s yang, and indeed strengthening Kidney yang will bolster all the yang of the body. Care must be taken, however, when Spleen yang is weak, as the Kidney yang supplements can be hard for some patients to digest. For basic yang warming and supplementation, you can’t go past Jin Kui Shen Qi Wan (Golden Book Teapills) or You Gui Wan (Right Side Replenishing Teapills). In combination with proper rest and nutrition, both will reliably restore yang over time. When the Spleen is weak, Li Zhong Wan can be used first to rebuild Spleen yang before embarking on Kidney supplementation, or they can be combined with one of the previously mention Kidney yang supplements.
Tiredness is both a symptom of illness and a condition of the modern fast paced world. As noted in the introduction, tiredness may accompany almost any illness, but it will be especially prominent or a major complaint of the pattern described above. A degree of persistence and flexibility in using or combining medicines, while closely scrutinizing diet, work, relationship and lifestyle issues for the causes of the disharmony will in most cases, yield good results.