xv. Why don’t doctors know?

28 November 2005 at 16:37 | Posted in Circadian rhythm | 11 Comments
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Not many doctors know anything about circadian rhythms.  Not even those calling themselves “sleep specialists” at “sleep clinics”.  Why? 
Well, the history of the field doesn’t go far back.  Some observations were made in the 1700s (the plant in the dark cupboard; Linne’s flower clock), 1800s (experiments and observations, again mostly on plants) and pre-WWII (humans in dark caves; photoperiodism – short and long day plants). 
Research and knowledge exploded in the last half of the 1900s.  In all directions, as explosions are wont to do.  Medicine studied brain waves and sleep stages in humans.  Biology, the mechanisms of seasonal migration and daily activity.  The terms “circadian rhythms” and “biological clock” weren’t even coined until less than a half a century ago.  There’s been constant work on all levels, evolutionary to molecular to wondering why organisms need to sleep at all.  Nature and nurture on all levels. 
No one can keep up with the details of all this as it is happening.  And no one is steering — setting priorities — except perhaps those who provide funding for research.  Someone has to choose what is sufficiently well documented and what is important enough for medical students to study. 
Apnea is widespread, dramatic (it kills) and treatable.  Fine.  Students learn about apnea.  Journalists pick up on and tell people about narcolepsy with cataplexy — both the words and the effects appeal; they sell newspapers.  Pills are provided for insomnia.  Sleep medicine is thus covered — on to the next item. 
Circadian rhythm disorders are “new”.  Discovered, defined and accepted by the 90s or so.  Many doctors now in practice were educated earlier than that and must be forgiven. 
The experts ’til now have been the psychiatrists and the neurologists.  Strange bedfellows, it seems to me, but that may just reveal how little I know about those fields.  In the USA, sleep medicine has now been approved as a sub-specialty for physicians practicing psychiatry, neurology, internal medicine and pediatrics. 
Requirements for the one year program include Chronobiological mechanismsCircadian rhythm disorders is mentioned under Treatment strategies.  The approval came in March 2005, and institutions wishing to offer the program were invited to apply for accreditation.  So no candidates can have completed the program to date.  That’s how new the field is!


Next post:  xvi. Treatment



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  1. Just wanted to say a couple of things really.

    First I want to say thanks for this amazing blog! It really is interesting to read about personal experience and the science behind it.

    Secondly – I’m 19 years old and live in the UK. In the past year I have started to think I have DSPS. I fall asleep at about 3:30 and wake up at about 2-3 If I am left to it. I have done for about 3-4 years now. I’ve been debating over a couple of things really. A lot of the time I think that perhaps I don’t have DSPS at all and that really I’m just using it as an excuse? Is this something others have felt like? I seem to be textbook but I’m so unsure.

    Thirdly – I am worried about going to my local doctor as I do not want to seem like I have set myself up with DSPS If I haven’t whilst on the other hand I don’t want to go through months of tests and pills for things I might not even have. The sleep centre links are unfortunately only for those in the USA 😦

    Finally – I recently left school and have not had a job since. University isn’t really an option because of the cost and me not doing great at school. I used to excel in the early years of school but recently my grades just declined. I believed until recently that It was down to my laziness. I then found out about DSPS but although I believe it played a part I still think my laziness was the main factor.
    My past history job wise has involved temporarily covering shifts at a nursing home from about 4-7PM. This left me napping at 7:30 and making sleep even more difficult. My real problem is that In the current climate jobs are difficult to get not least because of the catch 22.
    What I fear is If I’m lucky getting a number of simple jobs but getting fired because of being late or simply underperformance. Furthermore I worry that this history of potentially losing jobs will make it even more difficult to get one in the future. This stops me from looking for jobs.

    I am really sorry for making such a long post and am not looking for any practical thoughts on this really. Perhaps just some personal thoughts on it and lending an ear?


  2. Hello Jack. Thanks for the very nice words about the blog!
    The UK is unfortunately not the best place to be if one needs a diagnosis within the field of circadian rhythm disorders. A diagnosis isn’t much use, either, except for getting accommodations for school and possibly work hours. There aren’t any tests except for those used to rule out other diagnoses. DSPS and Non-24 are diagnosed based on interview and some weeks of sleep diary.
    One tiny hope is that you have the adolescent variety of DSPS which quits in one’s early 20s. Don’t count on that, though 😦
    If I may, I’d say that you may be selling yourself short. You write like an educated adult and likely are worth more than you seem to think you are. Have you looked at evening jobs? Like hotel, restaurant, taxi, postal service, shift work in industry…. There’s no reason you should expect to be fired from such a job!
    Yes, I suppose we’ve all wondered if we are just lazy or lacking in self-discipline. Once we know there is such a thing as DSPS, we may have to work at building self-esteem. I started late at that — it should be easier at your age? Good luck. You’ll be welcome on the mail list at circadiandisorders.org if you’d like to “meet” more of us.

  3. No problem 🙂

    Yes I’ve kind of decided against seeing a doctor for the time being as my dad bought me a light box. Feel quite guilty actually as I thought he wasn’t taking me seriously but then he told me he had been researching bright light therapy. These boxes really aren’t cheap although he said it was an early Christmas present so I hope it at least has some effect!
    I’m also keeping a sleep log using the sleepchart software although I only started this Monday 😦 Hoping it becomes easier to read the more data I fill in as I’m finding it fairly confusing right now! Don’t suppose their is a manual somewhere that I have managed to overlook?

    What a nuisance sleep can turn out to be! Still I will keep my fingers crossed over the coming years!

    Thank you very much for your kind words. I apologize for that paragraph. I have spent 3 days out of the last 7 unintentionally doing the 36 hour trick! This seems to have dragged my despair to the surface 😦 Feeling a lot more positive about things now that I have had a reasonably good nights rest! My dad wants some more help redecorating the house but once finished I think I will seek out some of the things you suggested.

    I’ve decided that regardless of whether or not it’s DSPS somethings definitely up with my sleep so at least I can go from their. Again you seem to be on the receiving end of my lack of sleep, sorry! I feel much more positive and self assured having slept.

    I joined the mailing group not long after this post 🙂 Not used to the format but definitely worth it to read some of the fascinating stories and research on there.

    Again sorry for the long post, just wanted to respond properly seeing as you made the effort to respond. Please don’t feel obliged to write back a long comment addressing all the points I made if at all!

    Thanks for your response!

  4. Just realised why you used full stops to separate paragraphs! Hope my comment doesn’t look like too much of a mess!

  5. The info about appetite not shifting was VERY interesting. I have never eaten breakfast, I can’t even stand the sight of food before 11 am, (as in the Weds edition of the NY Times DINING section- YUK in the morning, I fold it up for later)

    This is very revealing to me. Maybe it should be a part of the official diagnosis. Do you love to eat in the early morning after the alarm has ever so painfully blasted you out of nirvana?
    Thanks for this info!

  6. Makes sense, don’t you think? If the body clock is set to sleep 4 AM to noon, then the appetite appears at noon. Getting up at 8 AM is literally in the middle of the night for us. It’s as though any sleep we managed to get before 4, “doesn’t count”. Various other functions & hormones as well as the core body temperature rhythm are shifted, too. It all makes sense in a cruel sort of way. There just aren’t any jobs on the 1 PM to 9 PM shift.

  7. a couple of comments for delayed2sleep and for Jack: 1) the comment on CRD being only known in the fields of psychiatry and neurology. Not here in Canada, in my experience. I have not yet met a psychiatrist or psychologist who recognized my CRD, and I tell ALL of them about it (10-15 specialists in total)! In fact I have probably told every doctor I have seen since the mid 1980’s, that I function on a sleep clock that is closer to 25 hrs. most of them call it insomnia. then I tell them I sleep 9-12 hrs at a time. Then they just look confused and dismiss it.

    Jack, believe in yourself, keep yourself informed, and keep looking for a knowledgeable Dr. Don’t give up. I have been fighting both CRD and major depression since at least 1972, likely since infancy. Use your resources (family, friends, etc.) but first of all, be your own advocate! You have the most to gain. BM.

  8. I am lucky I have my own business. I have been able to sleep in as much as I want most days. Suddenly the bags that were under my eyes for 20 years are GONE! I look 10 years younger! I really sympathize with you guys with non-24, fortunately, I am 24 but can’t wake up before 11 am or noon.

    Most doctors in this country don’t know anything about basic sleep and basic nutrition, (pretty sure I have Celiac Disease- gluten intolerance). If your schedule allows, try to sleep when you want to.

    Now that I have solved my 2 biggest problems, sleep and fixing my digestion, I’m good to go from now on. This post has helped me a lot. Thanks guys!

  9. Right. The only treatment which works for Circadian Rhythm Disorders seems to be self-employment. A heads-up to young sufferers.

  10. I have the same appetite issue, I am never hungry in the morning. Appetite is controlled by the production of cortisol so maybe we shouldn’t be only focussing on Melatonin but should take cortisol also into the equation?

  11. Yes, the cortisol rhythm is part of the equation.

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