A worked case: sleeplessness in a 34-year-old teacher

The presentation

A 34-year-old schoolteacher, six months of difficulty falling asleep. She lies awake "with the whole day replaying". No pain. Sleep hygiene already tidy — no screens late, no evening coffee. Previous prescriptions from elsewhere: Coffea, then Passiflora. Neither held.

What the case actually gave

Insomnia is a diagnosis, not a symptom worth repertorising on its own. Everything below is what moved the case.

• Mind busy with the day''s events, specifically conversations she wishes she had answered differently
• Wakes around 3 a.m., then falls into heavy sleep near dawn and wakes exhausted
• Chilly; wants an extra blanket even in summer
• Volunteered, unprompted: "I get angry at myself for still being awake"
• Took on an additional administrative role eight months ago, works late, drinks 4–5 cups of tea a day
• Appetite fine; constipated, with frequent ineffectual urging

The reasoning

The 3 a.m. waking, the chilliness, the overwork with stimulants, and the ineffectual urging form one coherent general picture rather than four unrelated facts. The irritability is directed inward but has an impatient, self-reproaching quality rather than a grieving one.

Rubrics taken — six, not twenty:

1. Sleeplessness, thoughts, activity of, from
2. Waking, midnight, after — 3 a.m.
3. Chilly
4. Anger, himself, with
5. Urging, stool, ineffectual
6. Ailments from overexertion, mental

The prescription

Nux vomica, on the totality of the general state rather than on the sleeplessness. Sleep was the complaint; the overworked, stimulant-loaded, hyper-irritable state was the case.

Follow-up

At three weeks she reported falling asleep more easily and — the detail worth noticing — the bowel symptom had eased first, before the sleep did.

That order matters. Improvement in a general, appearing before improvement in the presenting complaint, is a reasonable indication that the remedy has engaged the whole state rather than palliated the symptom the patient came in about.

What to take from it

Two things.

First, the presenting complaint is rarely the case. Repertorised on insomnia rubrics alone, this analysis would have returned a list of sleep remedies and none of them would have fit.

Second, read the follow-up in the right order. What improves first tells you as much as whether anything improved at all. More worked cases in the case studies library.

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A teaching case, presented for study. Not a treatment recommendation; no case report substitutes for individual assessment.