Clinical Cases

A Case of Chronic Insomnia

Last modified on May 10th, 2018

Panagiotis Giotas

Dr. Panagiotis Giotas presents a case of chronic insomnia solved with a single remedy.

A Few Words About Insomnia

The term ‘’’’ refers to a person’s difficulty in falling and/or remaining asleep. When there is no obvious link to some other health problem, the insomnia is called primary, whereas, when it is associated with some other cause (coffee, alcohol, medications, etc.) or pathology (respiratory diseases, gastrointestinal diseases, musculoskeletal problems, depression, etc.), we call it secondary. Additionally, any kind of insomnia lasting less than a month is considered as acute insomnia, while chronic insomnia includes cases where the problem persists for more than a month. While the consequent sleep deprivation may initially lead to mild symptoms, such as drowsiness, difficulty concentrating, memory weakness, fatigue, etc., after a while, more serious symptoms like double vision, high blood pressure, or even hallucinations set in, rendering medical treatment absolutely essential. In homeopathic repertories insomnia is usually referred to as sleeplessness.

CASE TAKING

The patient is a 60 year old male, a retired professional, complaining mainly of severe insomnia. He is polite, composed, and his countenance and general attitude are quite serious, though he does react and responds by smiling at some of my jokes in the beginning of the interview.

He questions conventional medicine’s approach to the human organism, and fears the chemical drugs’ side effects, and this is the reason he decided to consult me, instead of resorting to sedatives, though he has occasionally used some in the past, while under the observation of other doctors.

The patient explains that his problems with sleep have started in the last 5 years, gradually becoming worse, reaching the current situation where he can hardly sleep (3). At night, he is tossing and turning constantly, watching the clock from midnight till morning, often getting up, then lying down again, to no avail. At morning and during the rest of the day he feels tired, both mentally and physically, but definitely much less tired than expected, since he states his median sleep duration lately (2 weeks) has been around 30 minutes to 1 hour a day at most. He is definitely concerned about his condition, but his reasoning ability seems intact. Furthermore, sleep during daytime is also rare. Whenever he manages to sleep a little, he does feel refreshed and ameliorated. Despite his sleep disturbance, he remembers having, every now and then, dreams of falling (1), and of devilish creatures (1), which do not really disturb him. Other than that, due to his sleeplessness, it’s difficult to extract reliable information about potential sleep peculiarities.

I ask him to talk a little about his character. He says he has always been a very shy person (3), and very closed and introverted (3). During our interaction he seems reasonably sociable and talkative, which makes me confront him about it. His reply is that his behavior is very deceptive, a well thought adaptation in order to live up to life’s needs, and that his current condition does not really leave him much choice, he has to open up in order to get help. He adds that this behavior did help him succeed in life, in combination with the fact he has always been very dedicated to his work. Part of his shyness is manifested in his difficulty with public speaking (1). The patient also says he is very sensitive to other peoples’ remarks (3), though he seldom shows it. Sometimes he cries (2), but this rarely occurs in front of other people (1). He doesn’t mention any specific fear, yet he claims having always been afraid to take any kind of risk (2) in any context, though he has been rewarded those few times he did step out of his comfort zone. Moreover, he seems to doubt himself (2). He has repeatedly proved himself capable of achieving things he never thought possible, and a little later he tends to attribute everything to mere luck. He understands he actually worked his way to achieving something, but doubts he could ever do it again, thus often hesitating to try.

He then spontaneously proceeds to narrate that while he has had a successful and fulfilling career, both he and his wife have always had to take care of their son, who is suffering from serious neurological problems since childhood. In homeopathy, when we hear about things of this kind, we always have to investigate deeper in order to evaluate the effect they might have had on the patient’s organism. After insisting on this point, the patient calmly declared that, while he loved his son and detested this whole situation, it is something they both have accepted a long time ago.

A mind symptom I considered significant enough to take was a peculiar aversion he had to music (2), which made him lower the TV or radio volume in any show he liked to follow, whenever some tune would start playing.

Excepting his severe sleeplessness, the patient’s general health seems to be good. He mentions headaches every now and then, backache, constipation occasionally, and oily skin, but all these appear too mild, common, and aspecific to be taken too much into consideration in a homeopathic interview, where we prefer ‘’the strange, the rare, and the peculiar’’, beside those truly strong symptoms. The patient has not noticed, nor does he remember any modalities (factors that cause aggravation or amelioration of a symptom), other than the fact such complaints usually, though not exclusively, appear in winter (2). He also states his mood in winter is worse. The chief complaint appears aggravated in winter as well, in fact the patient decided to consult me in late December. We must always be careful not to miss such information, even if it may initially seem, or later prove to be, insignificant.

The aggravation of this person’s symptoms in winter, may lead someone to believe it’s all due to the cold, hence that this person is aggravated by cold. In reality, previous centuries’ homeopaths, such as Kent, were very meticulous while assessing the human symptomatology and its modalities, distinguishing, for example, the aggravation during winter, from the aggravation by cold, and creating distinct rubrics in their repertories for each case.  This is for good reason, as later on, this patient denied being aggravated by cold. He liked both cold temperatures and cold air, preferring them to warmth, even if slightly.

Something that ameliorates the patient’s symptoms is vigorous walking or running (2), though he doesn’t always have the energy to do it and gets tired easily, due to his age. He even claims if he could run for 10-15 minutes, one hour before going to bed every night, maybe he would be able to sleep for 2-3 hours.

He thinks his sexual desire is decreased (2), which he attributes to his age and to not finding his wife attractive anymore, though his interest in other women is equally low.

Another fact that comes up during the interview is that the patient’s finger nails break easily (2).

His thirst is normal and he prefers water at room temperature. His perspiration is also normal, rarely offensive.

As to his dietary particularities, the patient desires Bread (3), Cheese (1), Highly-seasoned food (1), Pepper (2), Meat (2), and Eggs (2), and he is averse to Milk (2), and Fat (2).

During his life, the patient doesn’t remember having contracted any venereal disease. He was indifferent to alcohol, opposed to the idea of smoking, his weight has always been more or less normal, with no problem losing weight. He has always been careful with his health, thus avoiding allopathic drugs, unless really necessary, like lately. His blood pressure is a little higher than normal, but is not under any treatment currently.

As far as he can remember, he takes a cold every 2-3 years, sometimes with fever, sometimes not. His last acute was 2 years ago, a viral infection accompanied by cough, weakness, muscular pains, and fever (38,5 – 39 degrees Celsius), normal convalescence followed.

Going to the patient’s family history, both his parents enjoyed good health and died quite old, Father at 86 years old from pneumonia, Mother: 89 years old during sleep. Also, there was no genetic background, neither on the patient’s, nor on his wife’s, side, to explain or justify their son’s health problems which seemed to be acquired, not inherited.

REPERTORIZATION

In some homeopathic cases the indicated remedy becomes apparent from the very beginning of the interview but in others the remedy becomes apparent soon after having finished the interview and taking a good look at the symptoms one has recorded. Finally, there are those cases that require a careful repertorization in order to decide. Even though an expert homeopath may be able to analyze any case and reach the correct conclusion using exclusively his memory, repertorizing is always the wisest move, especially in a busy practice that often involves taking several difficult cases daily, resulting in a mind that soon becomes tired.

Let’s take a look at the repertorization of this case.

MIND – TIMIDITY  (3)

MIND – TIMIDITY, APPEARING IN PUBLIC  (1)

MIND – RESERVED  (3)

MIND – OFFENDED EASILY  (3)

**MIND – WEEPING, TEARFUL MOOD, ETC.   (2)

**MIND – WEEPING, TEARFUL MOOD, ETC. – ALONE, WHEN  (1)

MIND – COWARDICE  (2)

MIND – CONFIDENCE, WANT OF SELF  (2)

MIND – SENSITIVE, OVERSENSITIVE – MUSIC, TO  (2)

SLEEP – SLEEPLESSNESS  (3)

SLEEP – DREAMS – DEVILS  (1)

SLEEP – DREAMS – FALLING, OF  (1)

GENERALS – FOOD AND DRINKS – BREAD – DESIRE  (3)

GENERALS – FOOD AND DRINKS – CHEESE – DESIRE  (1)

GENERALS – FOOD AND DRINKS – HIGHLY SEASONED FOOD – DESIRE  (1)

GENERALS – FOOD AND DRINKS – PEPPER DESIRE – DESIRE  (2)

GENERALS – FOOD AND DRINKS – MEAT – DESIRE  (2)

GENERALS – FOOD AND DRINKS – EGGS – DESIRE  (2)

GENERALS – FOOD AND DRINKS – MILK – AVERSION  (2)

GENERALS – FOOD AND DRINKS – FAT – AVERSION  (2)

GENERALS – RUNNING – AMEL.  (2)

GENERALS – WINTER, IN  (2)

EXTREMITIES – NAILS – BRITTLE – FINGER NAILS  (2)

GENITALIA – MALE – SEXUAL DESIRE – DIMINISHED  (2)

** = These two rubrics were merged together as they describe the same symptom.

ANALYSIS

In order to find the most indicated remedy in a case, Vithoulkas has often summed up the most important strategies as follows: examining which remedies fit better with the totality of the symptoms, as Hahnemann used to suggest, considering which remedies’ keynotes are present and strong in the case, assessing which remedies fit better the general ‘’essence’’ of the case, namely the mental-emotional picture of the patient, and searching for the causative factors potentially involved in creating the current pathology.

Usually, employing one single strategy from the ones mentioned above, while ignoring the rest, proves to be insufficient in truly grasping the central idea of the patient’s pathology. Therefore, a careful, balanced combination of them is preferable in most cases.

Now, as to which remedies fit better the totality of this patient’s symptoms, let’s see the results of the repertorization, entering the 23 (24, with two merged) rubrics chosen above, in a repertorization software. I used Vithoulkas Compass, but the results should be pretty close in most modern repertories (flat repertorization).

16/23 : Sepia, Natrum muriaticum, Phosphorus

15/23 : Pulsatilla, Silica

14/23 : Calcarea carbonica, Sulphur, Ignatia, Mercury

12/23 : Lycopodium, Nux vomica, Aurum metallicum, Natrum carbonicum, Causticum Belladonna

Beside the mere quantity of present symptoms in each remedy, we have to take in serious consideration the underlines of the recorded symptoms. Ideally, the most indicated remedy should both include the thrice underlined symptoms, and also present them on the higher grade of intensity possible. Of course, this does not mean we should ignore the twice or even once underlined symptoms, especially when represented in the repertory by rubrics containing few remedies. These small rubrics must always be taken seriously, as they often constitute the pillars of successful differential diagnosis in homeopathic cases.

So, according to the underlines, this is above all, a very timid, reserved, easily offended patient, suffering from sleeplessness, and desiring bread, all these underlined three times. Keeping this in mind, we immediately realize that a remedy like Phosphorus doesn’t really fit this case, even if it covers 16 out of 23 rubrics. The same applies to remedies such as Silica, Sulphur, Ignatia, Mercury, Lycopodium, Nux vomica, Natrum carbonicum, Causticum and Belladonna. All of these remedies do have some of these strong symptoms, but in quite lower intensity normally. Moreover, remedies like Silica or Sulphur for example, may in fact both be very timid and suffer from severe sleeplessness, but the rest of the intense symptoms of this case are either missing or very mild in these remedies. Consequently, let’s focus on the remaining remedies: Sepia, Natrum muriaticum, Pulsatilla, Calcarea carbonica and Aurum metallicum.

Is this an Aurum metallicum case? The essence is there, as the patient is in fact serious, responsible, and used to be a hard worker. Aurum does cover all five thrice underlined symptoms, additionally being strongly aggravated in winter, though this rubric contains quite a lot of other remedies. It is also true that common Aurum characteristics, like suicidal thoughts, amelioration by music and praying, sobbing during sleep, etc., are missing here.

What about Calcarea carbonica? Normally Calcarea is neither that introverted, nor that easily offended as is this patient. Calcarea commonly has brittle nails, a strong desire for eggs, both present among the patient’s symptoms, underlined twice, but Calcarea does not desire bread, which is a very intense symptom here, underlined three times. Furthermore, the usual Calcarea fears are absent, exertion seems to actually ameliorate rather than aggravate in this case, there is no significant perspiration, no obesity, the person is not really chilly, etc. The pathological trends in this case appear quite distant from Calcarea’s.

And Pulsatilla? Notable Pulsatilla symptoms such as the aversion to fat and the tendency to weep are present in this case, both on the second grade. The patient likes cold air, and Pulsatilla can also be very timid, but even so, Pulsatilla patients, often feel lonely and abandoned, are definitely more extroverted and sociable than this patient, and typically crave affection and consolation, which ameliorate them. Also, in Pulsatilla, crying is not some shameful act that needs to be hidden from other people, which seems to be the case here.  Also Pulsatilla likes gentle motion. Vigorous walking and running, that also ameliorate, do not really remind us of Pulsatilla

This amelioration from running is definitely a keynote of Sepia, and the fact this remedy is so prominent in a very small rubric cannot be ignored. Sepia has, along with Natrum mur., the maximum of 16 out of the 23 symptoms, covers all five case symptoms that were underlined three times, is characterized by decreased sexual desire, like this patient, does present the patient’s peculiar aversion to music, can be averse to fat and milk, and, rarely, can even have brittle nails. Sepia patients are not particularly reserved, but on the other hand, seldom do we find remedies that cover everything and fit the patients’ symptomatology perfectly. Truth is Sepia seems like a solid prescription and there is very little that would contraindicate this remedy.

Lastly we have to investigate the possibility of Natrum muriaticum, that just like Sepia, covers 16 symptoms, including all of the five major ones. Typically, Natrum mur. patients are serious people, proper, very introverted, vulnerable enough emotionally to be quite easily offended, and often striving for perfection at work. Considering this, Natrum mur., beside the totality of the symptoms, definitely fits the essence of this case more than the previous remedies. In addition, a careful look at the smallest rubrics of the case makes us realize that Natrum mur. can also manifest some kind of aversion to music, is also among those few remedies that can be ameliorated by running, its crying fits usually happen when alone, and most importantly, it is one of the extremely few remedies of the whole Materia Medica that have a strong desire for pepper, just like the patient. Twice underlined symptoms contained in larger rubrics, like tearful mood, diminished sexual desire, aversion to fat and to milk, are covered by Natrum mur. pretty decently as well. So, as we can understand, Natrum mur. now becomes a much better fit for this case than Sepia

Something I initially didn’t like while examining Natrum mur. was the fact that, while insomnia was the major complaint in this case, this remedy was found on the second grade in the rubric of sleeplessness in the repertory. As a general rule, when taking a homeopathic case we should avoid fishing too much for mind symptoms, trying to extract from the patient information we imagine might be there. Spontaneous symptoms, that the patient offers by himself, are usually the most valuable ones. But sometimes, certain patients may understate the importance and the intensity of their problems. This specific patient, reserved, timid, and perhaps, deep down fearing ridicule, as Natrum mur. patients often do, represents exactly the kind of person, that would, and in fact did understate something quite important: the effect his son’s illness had on him over the years. Also, his emotional condition was perhaps something he was taking too much for granted. Coming back to this issue at the end of the interview with a little different phrasing than before, I finally confirmed this problem. This man has actually been grieving for quite a long time now. Therefore, another rubric should have been added and seriously considered:

SLEEP – SLEEPLESSNESS – GRIEF, FROM

This rubric contains very few remedies with Natrum mur. being the most prominent one, found on either the third or even the fourth grade of intensity, depending on the repertory used.

Evaluating the patient’s level of health, as analyzed by Vithoulkas, this man should probably be classified in upper group B, considering his age, life choices, genetic predisposition, susceptibility to acute disease, presence of fever, and ability to convalesce. Thus, despite the relative severity of his ailment, his prognosis is quite good.

I prescribed one dose of Natrum mur. 200CH, followed by another dose of Natrum mur. 1M the next day, placebo every day for nearly 50 days.

OUTCOME

On the follow up, after about 50 days, I immediately noticed the patient was more relaxed and less serious. He reported feeling a little strange the first two days after starting the treatment, and that his sleep got better almost immediately. Around the 10th-15th day he had a fight with his wife and the situation in the family got tense. Those days the insomnia recurred, though not completely. From the 15th day on, his condition started improving again.

The result was truly impressive and he confidently announced he was currently sleeping 7-8 hours daily and that falling asleep was much easier now. As expected after the restoration of his sleep, his physical and mental fatigue gradually subsided too. Assessing how much his energy improved is quite difficult, since the initial lack of sleep affected his energy levels as well.

As to his mental-emotional sphere, he said that he felt stronger and more balanced now, though his various mental symptoms persisted. ‘’Doctor, this is a better version of myself, but it’s still me, there are certain things I would like to see changed in the future’’. In group B patients, this is to be expected, as more layers of pathology lie below the uppermost layer (Natrum mur. in this case), and various symptoms, belonging to these lower layers, cannot be addressed immediately by the first remedy. For example, speaking hypothetically, his decreased sexual desire, could be explained by the presence of a Sepia, or a Silicea, or maybe a Lycopodium layer, below Natrum mur.

Finally, asking about any possible amelioration of local complaints, the patient reported his constipation was less frequent, he didn’t have any headache all these last weeks, and that he noticed his nails were much stronger now. After a brief search, I discovered that only Boenninghausen’s and Boericke’s repertories contain Natrum mur. among the remedies causing, and consequently curing, brittle finger nails, while it’s absent from Kent’s repertory.

In conclusion, this patient was progressing very well, so no intervention on my part appeared necessary at that point. I prescribed placebo pills for three months, asking to see him again after this period.

About the author

Panagiotis Giotas

Panagiotis Giotas

Panagiotis Giotas - I am a Medical Doctor who practices classical homeopathy in Greece. After graduating medical school, careful examination of available clinical evidence of homeopathy's efficacy and advantages compared to conventional medicine, lead me to become a homeopath and adopt homeopathy as my standard approach to human pathology and patient treatment. I was assigned by Prof. Vithoulkas to translate the International Academy' s (IACH) homeopathic e-learning program in the Greek language. I am a member of the Hellenic Homeopathic Medical Society and I teach homeopathy on behalf of the IACH in Greece.

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