A 35-year-old woman with a five-year history of severe sleep disturbances, palpitations, and fatigue was managed using a Liver and Kidney-tonifying herbal strategy.

Case ID: CHC-0034

Case Summary

This case describes a 35-year-old woman who presented with a five-year history of poor sleep that had become refractory to conventional sleeping pills. The original report documented a Western diagnosis of a sleep disorder and a TCM assessment of Insomnia (Bu Mei) driven by Liver and Kidney deficiency. The patient was managed through a dynamic herbal approach that prioritized tonifying the Liver and Kidneys to nourish the Heart, subsequently adapting to clear transient phlegm and consolidate blood production.

Patient Presentation

• Patient: 35-year-old female (Surname: Huang).
• Main Complaint: Poor sleep for 5 years, with poor response to long-term sleeping pills.
• History: The patient sought consultation on May 26, 2018. She reported significant difficulty falling asleep, frequent awakenings with many dreams, and an inability to return to sleep once awakened. Notably, she experienced mouth breathing after finally falling asleep. Associated symptoms included palpitations, being easily startled, a subjective feeling of heat in her chest, dizziness, tinnitus, forgetfulness, and soreness in her lower back and knees. She had a prior medical history of anemia.

Examination and Diagnosis

• Conventional Diagnosis: Sleep disorder.
• TCM Tongue and Pulse: The tongue was pale red with a thin, white coating. The pulse was floating and stringy (浮弦).

TCM Assessment

The original practitioner interpreted the presentation as Insomnia driven by Liver and Kidney Deficiency (不寐 – 肝肾不足).

According to the holistic principles of yin and yang Chinese Medicine the Liver stores blood and anchors the ethereal soul (Hun). The original report noted that the patient’s history of anemia led to an underlying state of blood deficiency. When the Liver fails to store adequate blood, the ethereal soul becomes unanchored and the mind loses its physical foundation, directly resulting in her severe insomnia, frequent dreams, and palpitations.

Concurrently, a deficiency in the Kidneys depletes the “marrow sea,” causing her dizziness, tinnitus, and forgetfulness, while depriving her lower back of nourishment, leading to the soreness. The pale red tongue and the floating, stringy pulse provided objective confirmation of this systemic Liver and Kidney depletion.

Treatment Approach

The primary treatment principle was to tonify the Liver and Kidneys, nourish the Heart, and calm the Spirit (补益肝肾，养心安神). The strategy aimed to physically rebuild the blood and essence required to anchor the nervous system, rather than relying on heavy sedatives.

Herbal Formulas and Modifications

• Initial Formula (May 26, 2018): A 12-herb decoction designed to nourish the Heart and soothe the Liver.
  • Nourishing Heart and Spirit: Chao Suan Zao Ren (10g), Zhi Yuan Zhi (10g), Fu Ling (30g), Gan Cao Pian (10g), Hei Zao (10g), and Shou Wu Teng (30g) formed the core to strongly replenish essence and blood, nourishing the Heart to calm the mind. Bai Zi Ren (10g) and Wu Wei Zi (10g) were added to enhance this spirit-calming effect.
  • Anchoring the Mind: Duan Mu Li (Calcined Oyster Shell, 30g) was heavily utilized to physically settle and sedate the agitated spirit.
  • Soothing Liver and Regulating Qi: Fu Chao Zhi Ke (10g), Cu Xiang Fu (10g), and Cu Yu Jin (10g) were included to gently soothe the stagnant Liver Qi and ensure the rich tonics did not cause digestive stagnation.
• Modifications (Subsequent Visits):
  • Second Visit (May 31): With her sleep and mouth breathing improving, Bai He (Lily Bulb, 15g) was added to clear the Heart and further calm the Spirit.
  • Third Visit (June 19): The patient developed a foreign body sensation in her throat (a classic sign of Phlegm-Qi constraint, or “plum-pit qi”). The practitioner dynamically removed Hei Zao, Suan Zao Ren, and Fu Ling, adding San Leng (10g), Xuan Shen (30g), Jiang Shui Ban Xia (10g), Zhu Ru (10g), and Shi Di (10g) to resolve the phlegm, dissipate the nodules, and invigorate blood.
  • Fifth Visit (July 3): With the insomnia and throat sensation largely resolved, the practitioner shifted focus to her underlying anemia and heavy menstruation. Dang Shen Pian (30g) and Bu Gu Zhi (15g) were added to deeply tonify the Spleen and Kidneys to promote fresh blood production.

Follow-Up

• Over the course of five visits spanning late May to early July 2018, the patient experienced a progressive resolution of her symptoms. The initial formula stabilized her sleep and halted the mouth breathing. After successfully clearing a transient episode of throat phlegm, the practitioner transitioned her to a restorative Spleen and Kidney tonifying regimen to consolidate her recovery and address her historical anemia.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the clear illustration of the TCM axiom: “Blood is the physical foundation of the mind.” The patient had relied on sleeping pills for 5 years without success because sedatives only forcefully suppress the nervous system; they cannot generate the physical blood required to anchor it.

The original practitioner traced the insomnia back to the patient’s history of anemia (Liver and Kidney deficiency). By prescribing blood-nourishing herbs like Shou Wu Teng and Suan Zao Ren, the treatment rebuilt her physical reserves. Furthermore, the clinical agility in the later visits is highly instructive: when the patient developed a throat blockage, the practitioner immediately pivoted to phlegm-resolving herbs, and once cleared, pivoted again to Spleen tonics (Dang Shen) to permanently fix the blood deficiency, achieving a holistic resolution.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Qingyuan Maternal and Child Health Hospital (清远市妇幼保健院) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】曾宪进：补益肝肾法治疗肝肾不足型睡眠障碍案
• Practitioner: Professor Zeng Xianjin (曾宪进)
• Publication date: September 30, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation