A 49-year-old man suffering from a two-year history of severe stress-induced insomnia and daytime fatigue was managed using a Liver-soothing and Phlegm-Heat clearing herbal strategy.

Case ID: CHC-0033

Case Summary

This case describes a 49-year-old man who presented with a two-year history of severe insomnia triggered by immense business and financial stress. The original report documented a conventional diagnosis of a sleep disorder and a TCM assessment of Insomnia (Bu Mei) driven by Liver Qi stagnation and internal Phlegm-Heat disturbance. The patient was managed through a comprehensive herbal approach designed to clear the physical accumulation of phlegm and heat while simultaneously anchoring the mind and soothing his emotional stress.

Patient Presentation

• Patient: 49-year-old male (Surname: Li).
• Main Complaint: Difficulty falling asleep accompanied by mental fatigue.
• History: The patient sought consultation on March 1, 2023. He reported that over the past two years, significant operational issues within his company had caused him massive life stress, resulting in chronic insomnia. He had previously sought multiple medical consultations and relied on conventional Western sleep medications. While these drugs provided temporary sleep, they consistently left him feeling dizzy and profoundly fatigued upon waking, failing to resolve the root cause. Associated symptoms included a bitter taste in his mouth and a dry throat.

Examination and Diagnosis

• Conventional Diagnosis: Sleep disorder.
• TCM Tongue and Pulse: The tongue was dark red with a yellow, greasy coating. The pulse was stringy and slippery (弦滑).

TCM Assessment

The original practitioner interpreted the presentation as Insomnia driven by Liver Qi Stagnation and internal Phlegm-Heat Disturbance (肝郁气滞，痰热内扰).

According to the principles of yin and yang Chinese Medicine the Liver governs the smooth flow of emotions and Qi throughout the body. The original report noted that the patient’s immense, prolonged business pressure severely constrained his Liver Qi. Over time, this stagnant energy generated internal pathological heat (evidenced by the dark red tongue, bitter taste, and dry throat).

Simultaneously, chronic stress impairs the Spleen’s digestive functions, leading to the accumulation of internal dampness, which the heat then “cooks” into thick Phlegm (objectively confirmed by the yellow, greasy tongue coating and slippery pulse). This combination of volatile Liver heat and heavy, turbid Phlegm drifted upward to harass the Heart and disturb the Mind (Shen), making restful sleep impossible.

Treatment Approach

The primary treatment principle was to soothe the Liver, resolve depression, clear heat, transform phlegm, and calm the spirit (疏肝解郁，清热化痰，安神定志). The strategy intentionally avoided heavy, purely sedating agents (which had previously caused his “hangover” effect), opting instead to physically clear the inflammatory heat and dampness from his digestive and biliary tracts.

Herbal Formulas and Modifications

• Formula Prescribed (Initial Visit – March 1, 2023): The practitioner prescribed a modified version of the classical formula Chaiqin Wendan Tang (Bupleurum and Scutellaria Decoction to Warm the Gallbladder), utilizing 13 precisely chosen herbs.
  • Soothing the Liver and Clearing Heat: Chai Hu (Bupleurum, 15g) and Huang Qin (Scutellaria, 10g) formed the core pair to vent stagnant Liver Qi and clear the trapped heat.
  • Transforming Phlegm and Regulating Qi: Jiang Zhu Ru (Ginger-processed Bamboo Shavings, 20g), Zhi Shi (Immature Bitter Orange, 10g), and Jie Geng (Platycodon, 15g) worked synergistically to powerfully resolve the sticky phlegm and restore the proper ascending and descending movement of the torso’s Qi.
  • Moving Qi and Relieving Stagnation: Mu Xiang (Aucklandia, 10g) and Hou Po (Magnolia Bark, 10g) were added to unblock the digestive tract and relieve abdominal fullness.
  • Strengthening the Spleen and Draining Dampness: Ze Xie (Alisma, 15g), Bai Zhu (Atractylodes, 15g), and Fu Ling (Poria, 20g) fortified the digestive system to eliminate the root source of the phlegm, safely flushing the dampness out through urination.
  • Calming the Spirit: Yuan Zhi (Polygala, 15g) cleared phlegm from the sensory orifices, while the heavy, mineral-based herbs Long Gu (Dragon Bone, 30g) and Mu Li (Oyster Shell, 30g) were utilized to strongly anchor the floating Yang and settle the agitated mind.

Follow-Up

• March 8, 2023 (Second Visit): After consuming the initial seven doses (taken warm, morning and evening), the source reported a significant clinical improvement. The patient stated that his sleep was vastly better, allowing him to sleep peacefully for several hours each night without the grogginess associated with his previous medications. The practitioner prescribed an additional seven doses of the identical formula to consolidate the therapeutic gains and specifically advised him to regulate his emotions and avoid overexertion.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is its approach to modern, stress-induced psychiatric symptoms. In high-pressure environments, it is common to treat insomnia by forcing the brain to shut down with sedatives, which often leads to the exact daytime grogginess and fatigue this patient experienced.

The original practitioner recognized that the insomnia was not merely a neurological lack of sleep, but the result of a physical, metabolic “swamp” (Phlegm-Heat) generated by chronic stress. By utilizing Chaiqin Wendan Tang to literally cool down the Liver and clean out the digestive tract’s phlegm-dampness, the treatment removed the physical irritants harassing the nervous system. This demonstrates the classical TCM wisdom that a calm mind requires a clean, unobstructed internal physical environment.

---

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: Guangdong Provincial Administration of Traditional Chinese Medicine / Beijing University of Chinese Medicine Shenzhen Hospital (Longgang)
• Original title: 【以案说医】王进东：肝郁痰扰眠难安，柴芩温胆复梦甜
• Practitioner: Professor Wang Jindong (王进东)
• Publication date: October 9, 2024
• Original language: Chinese
• ChineseHerb.org version: English translation and editorial adaptation