A 51-year-old woman with a two-year history of refractory insomnia was treated by harmonizing the stomach and resolving phlegm-fire.

Case ID: CHC-0005

Case Summary

This case describes a 51-year-old woman who presented with chronic insomnia lasting two years, complicated by a recent onset of poor appetite and digestive discomfort. The original report documented a conventional diagnosis of a sleep disorder and a TCM assessment of Phlegm-Fire disturbing the mind combined with Spleen and Stomach weakness. The practitioner managed the condition using a modified version of Huanglian Wendan Tang to regulate digestion and calm the spirit.

Patient Presentation

• Patient: 51-year-old female.
• Main Complaint: Insomnia for two years, accompanied by poor appetite for the past week.
• History: The patient reported a two-year history of sleep disturbances with no obvious trigger. Her symptoms included difficulty falling asleep, frequent awakenings, an inability to return to sleep, and significant morning fatigue. She had previously used conventional sleep aids with recurrent relapses. One week prior to the consultation, she developed a loss of appetite, dry mouth, a bitter taste, and difficult-to-expectorate phlegm, though she did not have a cough.

Examination and Diagnosis

• Conventional Diagnosis: Sleep disorder.
• TCM Tongue and Pulse: The tongue was dark pale with a yellow coating. The pulse was stringy (弦).
• Physical Examination: General physical and systemic examinations were largely unremarkable, with no major underlying medical history.

TCM Assessment

The original practitioner interpreted the presentation as Phlegm-Fire disturbing the mind, combined with Spleen and Stomach weakness (痰火扰神兼脾胃虚弱).

Within the framework of yin and yang Chinese Medicine, restful sleep requires a smooth, harmonious transition from the active Yang phase of the day into the quiet Yin phase of the night. In this patient, a weak Spleen and Stomach failed to properly process fluids, leading to the accumulation of dampness and phlegm. Over time, this stagnant phlegm generated heat (Fire). This resulting Phlegm-Fire drifted upward to harass the Heart (the residence of the mind/Shen), disrupting the body’s natural ability to settle into the Yin phase, thereby causing severe insomnia, a bitter taste in the mouth, and irritability.

Treatment Approach

The primary treatment principle was to regulate Qi, resolve phlegm, strengthen the Spleen, and harmonize the Stomach. Rather than relying solely on heavy herbal sedatives, the strategy focused on clearing the digestive tract of the pathogenic phlegm-fire that was agitating the nervous system.

Herbal Formulas and Modifications

• Formula Prescribed: A modified version of Huanglian Wendan Tang (Coptis Decoction to Warm the Gallbladder).
• Action and Composition:
  • Clearing Heat and Phlegm: Huang Lian (Coptis) clears heat and transforms phlegm, while Ban Xia (Pinellia) dries dampness.
  • Harmonizing the Stomach: Ban Xia (which is warm) was paired with Zhu Ru (Bamboo shavings, which is cool) to balance the stomach and clear irritating heat. Chen Pi (Tangerine peel) was used to regulate Qi and resolve stagnation.
  • Strengthening the Spleen: Fu Ling (Poria), Shu Dang Shen (Prepared Codonopsis), and Bai Zhu (Atractylodes) were included to tonify Qi and strengthen the Spleen, addressing the root cause of the phlegm production.
  • Calming the Mind: Suan Zao Ren (Sour Jujube Seed), Zhi Yuan Zhi (Polygala), and Lian Zi Xin (Lotus Plumule) were added specifically to nourish the Heart, clear internal restlessness, and anchor the spirit for better sleep. Xiang Fu (Cyperus) was included to soothe Liver Qi.

Follow-Up

(Note: Specific follow-up consultation data and long-term outcomes were not detailed in the original excerpt of this medical case.)

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the classical TCM application of the principle: “If the stomach is not harmonized, sleep will be restless” (胃不和则卧不安). The patient suffered from chronic insomnia for two years, but the recent onset of poor appetite, sticky phlegm, and a bitter taste provided the critical diagnostic clue.

The original practitioner recognized that the root of the sleeplessness was not primarily in the brain, but in the gut. By utilizing Huanglian Wendan Tang to clear the digestive stagnation and resolve the upward-flaring Phlegm-Fire, the treatment aimed to restore the physiological environment necessary for sleep. This highlights the holistic diagnostic reasoning of TCM, where treating a sleep disorder often involves repairing the digestive system.

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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: Dongguan Hospital of Traditional Chinese Medicine (东莞市中医院) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 【以案说医】董明国：理气化痰，健脾和胃治疗睡眠障碍案
• Practitioner: Professor Dong Mingguo (董明国)
• Publication date: November 8, 2024
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation