Treating Two Refractory Insomnia Cases with Modified Guizhi Plus Gegen Decoction: A Clinical Experience

Case 1: A 57-year-old woman surnamed Yu, a Beijing resident, first consulted me by video on May 10, 2024.

The patient had long favored meat but had switched to a light diet over the past five years, and three months earlier had begun a low-fat, pure-vegan diet. She had a long-standing diagnosis of hypertension and had been taking antihypertensive medication for years. She had suffered from intractable insomnia for many years and had visited several hospitals in Beijing without much benefit. She was eager to improve her sleep, because poor sleep had made her emotionally unstable and had worsened her hypertension.

During the inquiry I learned that she had long been aware of a splashing sound in her stomach, along with acid regurgitation, heartburn, aversion to cold, stiffness and tightness of the back, hand eczema, and easy sweating. Since we had not met in person, I could not take the pulse. Based on her reported symptoms, she had what Chinese medicine calls a combined Taiyang disease and fluid-retention (yin) disorder.

Guizhi plus Gegen Decoction and Gegen Decoction both treat Taiyang disease presenting with "stiff and tight nape and back." Guizhi plus Gegen Decoction is for the "stiff nape and back" in patients who sweat easily, while Gegen Decoction is for those who do not sweat easily or do not sweat at all. Following the principle of "when the pattern is present, use the corresponding formula," I chose Guizhi plus Gegen Decoction. The splashing sound in the stomach indicated a "fluid-retention" disorder, and of the many formulas for fluid retention, Linggui Zhugan Decoction best matched her presentation. I therefore combined Guizhi plus Gegen Decoction with Linggui Zhugan Decoction, without directly targeting her "insomnia."

As the senior TCM professor Yin Huihe pointed out, in treating illness one must learn to "grasp the primary pattern" and choose the formula accordingly. Once the primary pattern is resolved, secondary symptoms that were hard to treat often disappear unexpectedly on their own.

The final prescription was: Guizhi (Cassia Twig) 10 g, Baishao (White Peony) 10 g, Chao Baizhu (stir-fried Atractylodes) 10 g, Gegen (Kudzu Root) 20 g, Fuling (Poria) 10 g, Zhi Gancao (honey-fried Licorice) 6 g, Shengjiang (Fresh Ginger) 15 g, Dazao (Jujube) 7 pieces. One dose daily, decocted in water, taken warm in the morning and evening.

About a week after starting, the patient reported that the splashing sound had lessened but had not completely disappeared. To her surprise, her years-long intractable insomnia had miraculously resolved; she had expected it would take a long course of treatment.

Not a single herb in this formula directly treats insomnia, yet it cured her insomnia. The reason is that her insomnia was only a secondary symptom; what truly troubled her was the Taiyang exterior pattern and the fluid-retention disorder. Once the root problem was addressed, the insomnia resolved without being specifically targeted.

Case 2: A 34-year-old man surnamed Chen, residing in Chengdu, first consulted me remotely on June 30, 2024.

The patient had worked a desk job for many years. After contracting COVID-19, he had suffered insomnia for over half a year and had sought treatment everywhere without benefit. He had difficulty falling asleep, tended to wake between 3 and 4 a.m., and then needed to urinate; he also felt a certain heat and stickiness in his body at night, and his abdomen often contained gas that moved around. He had sought treatment in Chengdu from both Chinese and Western doctors without effect. Melatonin did not help and instead gave him headaches. Western doctors proposed anti-anxiety medication, which he declined. The inquiry revealed that he sweated easily, had aversion to wind and cold (especially on the head), and had stiff, tight shoulders and neck. Because the consultation was remote, I could not take the pulse.

His nocturnal heat and stickiness, with a suspicion of low-grade fever, suggested that an exterior pattern still remained. Easy sweating, aversion to wind and cold are all symptoms of the "Taiyang wind-strike pattern" in the Shanghan Lun, and the stiff, tight shoulders and neck match the "stiff and tight nape and back" of the Guizhi plus Gegen Decoction pattern. These symptoms after COVID-19 constitute one of its sequelae. His difficulty sleeping at night and irritability suggested the "torpor and oppression in the heart" described for Zhizi and Dan Douchi Decoction (Gardenia and Prepared Soybean Decoction). I therefore combined Guizhi plus Gegen Decoction with Zhizi and Dan Douchi Decoction and added Fuxiaomai (light wheat) to astringe yin and stop sweating.

The prescription was: Guizhi 15 g, Baishao 15 g, Gegen 30 g, Fuxiaomai 30 g, Zhizi (Gardenia) 10 g, Dan Douchi (Prepared Soybean) 10 g, Zhi Gancao 10 g, Shengjiang 7 slices, Dazao 7 pieces (crushed). Five doses, decocted in water, taken warm morning and evening.

After five doses, the patient reported that falling asleep was markedly easier, the nocturnal heat and stickiness were gone, and he could readily fall back asleep after waking at night. His stools had become loose, which is a side effect of Zhizi. Since his "torpor and oppression in the heart" had resolved, he no longer needed Zhizi and Dan Douchi; I told him to omit Dan Douchi and Zhizi and continue another five doses to consolidate the effect.

Both insomniac patients had seen many Chinese and Western doctors. Both Chinese and Western physicians were misled by the chief complaint of "insomnia" and prescribed the usual sleeping medications, none of which worked. Learning from the earlier doctors' mistake, I avoided circling around this line of thought and instead followed Professor Yin Huihe's idea of "grasping the primary pattern," using the patients' other, more important symptoms to determine which formula was indicated and then treating the pattern. In this way, both patients' insomnia was resolved simultaneously.

Thus, in treating any disease, one must value pattern differentiation and careful analysis. The physician must have independent judgment and must not be misled by the patient's chief complaint; only then can we grasp the principal contradiction. Once the principal contradiction is resolved, secondary problems resolve without being specifically treated. Whether in Chinese or Western medicine, the clinical process should first analyze the condition and then target treatment accordingly.

In fact, my prescriptions for these two patients were issued very quickly—only three to five minutes each—rather than taking ten or more minutes or half an hour of deliberation. The difference is that when analyzing their conditions, I stepped outside the simplistic "treat the head when it aches, treat the foot when it hurts" mindset and synthesized the overall picture.