Pathogenesis evolution and treatment of insomnia with comorbid anxiety and depression symptoms based on the theory of "five evolutive phases and six climatic factors—opening-closing-pivoting"

Insomnia with comorbid anxiety and depression symptoms severely impairs patients′ sleep quality and emotional state, reduces their ability for daily activities, and compromises quality of life. As a clinically prevalent and refractory psychoemotional disorder, it falls into the traditional Chinese medicine (TCM) categories of "Bumei" ("inability to sleep") and "depression syndrome." Based on the "five evolutive phases and six climatic factors—opening-closing-pivoting" theoretical framework, we propose that dysregulation of the five evolutive phases with reversal and opening-closing-pivoting mechanism disorder constitutes the core pathogenesis of insomnia with comorbid anxiety and depression symptoms, and runs throughout the entire disease course. This is specifically manifested as six pathological dysregulation states in the climatic evolutive phases, leading to disordered opening-closing-pivoting: excessive water evolution result in cold obstruction and failure of Taiyang to open; excessive fire evolution leads to phlegm-heat and failure of Yangming to close; insufficient wood evolution leads to damp stagnation and loss of pivoting in Shaoyang; insufficient earth evolution result in qi deficiency and failure of Taiyin to open; excessive wood evolution leads to liver fire and failure of Jueyin to close; and insufficient metal evolution result in yin deficiency and loss of pivoting in Shaoyin. On this basis, the core therapeutic principle for insomnia with comorbid anxiety and depression symptoms is established as regulating the five evolutive phases, restoring opening-closing, and unblocking the pivoting mechanism. Six corresponding treatment methods are respectively applied: warming yang and dispelling cold to unblock the Taiyang opening; clearing heat and resolving phlegm to descend the Yangming closing; soothing wood and promoting earth to regulate Shaoyang pivoting; fortifying earth and tonifying qi to activate Taiyin opening; clearing the liver and draining fire to consolidate Jueyin closing; and nourishing yin and descending fire to restore Shaoyin pivoting, combined with matched prescriptions and medicinals. By harmonizing movements and qi dynamics and restoring the normal state of opening-closing-pivoting, the mind can be nourished, and emotions can be naturally harmonized, thereby providing a theoretical reference and a diagnostic and therapeutic approach for TCM syndrome differentiation and treatment of insomnia with comorbid anxiety and depression symptoms.