A 44-year-old female outpatient of German origin, who had been suffering from long-term schizophrenia (length of illness: 16 years) and (subjective) sleep disorders, was the subject of this study. The patient was diagnosed by experienced psychiatrists and was found to be suffering from paranoid schizophrenia, F20.0 according to the International Classification of Diseases-10, and schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders-V. The patient had normal intelligence (IQ = 88, as measured with the MWTB test), and she had finished "Hauptschule" education, which is secondary school in Germany. The patient was on medication during the whole study. She used amisulpride (200 mg in the morning), olanzapine (5 mg at night), and pramipexole (0.70 mg in the evening).
The patient was suffering from severe recurrent psychosis involving repetitive delusions. During psychotic episodes, she would have the feeling that another person, that is, the devil, was residing in her. Moreover, she was suffering from severe sleep disorders, including insomnia, frequent awakenings, and nightmares. She was also suffering from social dysfunctioning and restlessness and had had the feeling of being different within, as well as outside, the body; sometimes, she exhibited catatonic behavior. During psychosis, she would have the disturbing impression that things, such as doors and her own hands, had changed and become larger. Moreover, she claimed to feel the soul of her best friend. She was also suffering from severe anxiety with mood changes from disturbed laughing to extensive crying. Sometimes, she would feel as if someone had pushed away her feet when she was seated, and, sometimes, she would see different people present in the bodies of her friends. Finally, she would have the feeling of being observed all the time.
Approval was received from the local ethics committee (Arztekammer Nordrhein, number 2008331) for this clinical case study; moreover, the study is part of a larger project that has officially been registered under number NTR3132 at the Dutch Trial Register. The following study protocol was used: (1) a psychological assessment was conducted using the Pittsburgh Sleep Quality Index (PSQI) in order to measure subjective quality of sleep, the digit span forward and backward in order to measure simple working memory performance, the letter-number sequencing task in order to measure complex working memory performance, and the Positive and Negative Syndrome Scale (PANSS) filled in by her psychiatrist in order to monitor the positive and the negative symptoms. Her psychiatrist had had more than 20 years of psychiatric experience in the LVR-Klinik Bedburg-Hau and had been trained in using the PANSS. Moreover, the psychiatrist was not involved in and/or informed about our research project. In addition, the patient wore an actiwatch (Type: Actiwatch Spectrum Plus, http://www.actigraphy.com/devices/actiwatch/actiwatch-plus.html) for 14 days, 24 hours a day, in advance of the clinical nonpharmacological intervention in order to collect data on the following seven sleep parameters: "sleep efficiency," "sleep latency," "absolute actual sleep time," "absolute actual wake time," "relative actual sleep time," "relative actual wake time," and "assumed sleep" (meaning the difference between the end of sleep and the start of sleep). (2) Then, after careful diagnosis by a licensed Oriental medical practitioner with more than five years of clinical experience, the patient received individualized manual acupuncture in accordance with traditional Chinese medicine principles. Single-use stainless-steel needles (Type: AcuPro C, Wujiang City Cloud & Dragon Medical Device Co., Ltd., China) were used. The patient was treated weekly in the clinic for twelve consecutive acupuncture treatments, and each acupuncture treatment lasted about 60 minutes (for a detailed overview of the exact acupuncture points and frequency that were used during the 12 weekly acupuncture treatments, we refer the reader to Figure 1).
For each separate acupuncture needle used in the treatment, the needle was inserted and deqi was achieved. The needle was then left in place for one hour, after which it was taken out. (3) After the 12 weeks of treatment, a second psychological assessment was completed using the same psychological tests that had been used in the first psychological assessment. Moreover, again, she put on and wore an actiwatch for 14 days, 24 hours a day. (4) Finally, three months after having finished the acupuncture treatment, a third psychological assessment was completed using the same psychological tests as in the first and the second psychological assessments in order to investigate possible long-lasting treatment effects.
As can be seen in Table 1, the psychological assessment results show no differences in the PANSS positive and the PANSS negative subscale scores before acupuncture, immediately after the acupuncture treatment period, and three months after the acupuncture treatment period, with all scores remaining stable at 7. The PANSS psychopathology score was observed to have decreased from 38 before acupuncture to 30 immediately after the acupuncture treatment period but to have increased to 33 at follow-up, three months after having finished acupuncture treatment. The PANSS total score was observed to have decreased from 52 before acupuncture to 44 immediately after the acupuncture treatment period but to have increased to 47 at follow-up. The PSQI total results showed a decrease from 9 before acupuncture to 3 immediately after the acupuncture treatment period, but, after three months, an increase to 10 was noted. In the literature, three empirically derived factors have been proposed, for example, sleep efficiency, perceived sleep quality, and daily disturbances, that according to the authors should be favored over the single factor PSQI total score. However, further research is ongoing and we therefore decided to report all seven components instead of the three, in order to give all necessary information. As can be seen in Table 1, the factor PSQI subjective sleep quality decreased from 1 before acupuncture to 0 after acupuncture, and it then increased to 3. The factor PSQI sleep latency first decreases from 3 to 1 and then increases back to 2 at follow-up. The factor PSQI sleep time increases from 0 to 1 in score (indicating a more problematic sleep time) after acupuncture but then decreases again. The factor PSQI sleep efficiency does not change between T1 and T2 but increases to 3 at follow-up. The factor PSQI sleep disorders decreases after acupuncture and then stays that way. The factor PSQI sleep medication decreases after the first measurement and does not change again after that. The factor PSQI daytime sleepiness remains at zero until it increases to 1 at follow-up. The factor PSQI subjective time to fall asleep in minutes decreases markedly after T1 in which the patient estimated that it took approximately 60 minutes to fall asleep each day. After acupuncture, she fell asleep after only thirty minutes and this further improved to 4.5 minutes at follow-up. The factor PSQI subjective sleep duration in hours consisted of the total sleep time that the patient filled in on the form, and it decreased dramatically after acupuncture and stayed approximately the same at follow-up. The digit span results showed an increase from 7 before acupuncture to 10 immediately after the acupuncture treatment period and remained stable at 10 three months after having finished the acupuncture treatment. Finally, the letter-number sequencing results showed an increase from 2 before acupuncture to 6 immediately after acupuncture treatment and remained relatively stable and even slightly increased up to 7, three months after having finished the acupuncture treatment.
Moreover, as can be seen in Table 2, the actiwatch results before acupuncture treatment versus those after acupuncture treatment showed a statistically significant decrease in the scores for "sleep latency" (t = -3.25, p = 0.006). Moreover, a certain trend towards significance was found for the sleep parameters "sleep efficiency" (t = 1.89, p = 0.08) and "absolute actual wake time" (t = -1.89, p = 0.08). More specifically, "sleep efficiency" increased from 80.31% to 85.64% while "absolute actual wake time" went down from 107.30 minutes to 73.38 minutes after acupuncture treatment. Finally, no statistically significant change or trend towards significance was found for "absolute actual sleep time" (t = -1.09, p = 0.30), "relative actual sleep" (t = 1.58, p = 0.14), "relative actual wake" (t = -1.58, p = 0.14), and "assumed sleep" (t = -1.70, p = 0.11) (all raw actiwatch data for our patient are presented in Supplementary Table 3 in Supplementary Material available online at http://dx.doi.org/10.1155/2016/6745618).