Why doctors are (sorta) wrong about treating N24 as a "symptom"
We were discussing the problem of Doctors treating N24 as "Insomnia" (If you hear hoofsteps, suspect a horse, not a zebra) and then viewing it as a symptom of underlying disorder, rather than as a standalone diagnosis, and a commenter asked, "Yes, but are they wrong?" And I thought that was a good question worthy of an attempt at an answer (Thank you for the comment!). So here's mine:
They aren't wrong from their point of view. And they have good reasons for thinking the way that they do. But they are wrong in a subtle sense. In general, you can't treat a symptom. You treat an underlying cause. If all you have is a symptom, you can't do anything. For instance, "headache". If a patient has a headache, you don't look at a list of causes for headache, and start with "Astrocytoma" because it's first on the list, and immediately prescribe brain surgery. A doctor would (rightly) search for the underlying cause of the headache before cutting into the patient's brain.
But with N24, the cause is basically unknown. The proper path is… I will address what they should be, but aren't doing a little later.
Their instinct with a "causeless" symptom like N24 is to group it with other symptoms and see what common causes there are for the symptom cluster. This leads them to a few treatment pathways and patient pipelines that completely miss what's going on and send people with N24 into decades long blind alleys following useless treatment protocols some of which have extreme adverse effects.
The first thing they do is simplify "N24" (something they haven't heard of, and the "rule of thumb" they follow is: if you hear hoofprints, don't think of a zebra, think of a horse) to "Insomnia". Then, if you are overweight, Insomnia + Overweight = sleep apnea!
BAM! Refer to sleep clinic! I AM A GOOD DOCTOR! I GET AN A+!
PROBLEM SOLVED Go golfing.
Six months later, patient returns. They are wearing a Darth Vader mask and still complaining about Insomnia. They said something about "N24" but you aren't listening. You are looking at their chart and their chart says, "Insomnia". And patients are idiots (and you're almost always right in assuming this). And they seem a little… crazy…
So start them down the psych pipeline. Insomnia plus generally frazzled? DEPRESSION… Refer them to the Behavioral Clinic.
PROBLEM SOLVED! You are a good doctor! You get an A+! Go golfing.
And when you get to the behavioral clinic? Well… Now you're in for six to fifty years of varied and fashionable treatment pipelines that will leave you 500 pounds overweight, groggy all the time, in a straitjacket, delirious, locked in a padded room, drooling into your pillow, wondering where your life went, if you are capable of any thought at all. But still nothing is being done to address the circadian rhythm disorder. Because it is "just a symptom" of depression/anxiety/… (They will treat your "sleep problems" as a symptom of 100 different "underlying causes" as long as your insurance holds out).
So what should they do?
Basic science. Drop all assumptions about what is causal for the symptom. Drop all assumptions about WHAT IS "NORMAL." Some people can climb Mt. Everest without oxygen. That's very rare. Do they have a disease? No. They are different in some way. Some people stay awake for 26 hours and then sleep for 13. Are they diseased? Perverted? Let's NOT ASSUME ANYTHING. Let's do some basic science. Just because a person's behavior is different from some norm expected of them doesn't necessarily mean they are "diseased." And the norm of sleeping like a machine in a factory arose with factories about two hundred years ago.
So what would basic science look like? Drop the assumption that a person is "supposed" to be awake for 16 hours and sleep for 8 like they are a machine with an on and an off switch. If you tell a group of people that they hold this assumption, they will say, "I never said anything like that!" And indeed, they never did. They assumed it, without ever having thought about it, which is revealed by looking at the methodology and analysis of every sleep study ever conducted. It is never said, no one needs to say it. They all assume it, without thought.
Drop that assumption, and observe. "Allow" the person to sleep when they are tired and be awake when they are awake. Take an actigraph. Take saliva samples every hour and track hormone cycles. Put the person in a fmri and observe how their brain functions. And do the same things for a control group… TWO control groups, in fact. Control Group One: people living "normal" lives. You know the type. Every day, they wake up, guzzle two gallons of coffee, go to a panicked workplace, come home in a state of panic and anxiety. Watch tv for eight hours, take a Xanax, sleep (barely) for 6 hours, wake up, guzzle two gallons of coffee and do it all again, and then sleep twelve hours on Saturday and Sunday. Control Group Two: People who "never had a problem" with sleep. They fall asleep at 10 o'clock at night and wake up at 6, no problem, ever since they were a kid.
Then you might, might start to see something. Then you might have a leg to stand on, a wobbly one, scientifically.
How much would such a study cost? A billion dollars? How many people does N24 affect? 0.05%? Is it worth it? Nope. Would you initiate a billion dollar study to try to take people who can climb Mt. Everest without oxygen and make them into people who can't climb Mt. Everest without oxygen? Nope. So people with N24? Thrown out like garbage. Your chronotype doesn't match societal expectation… B'bye! Have a nice life, you useless sack of crap. Or… go to the sleep clinic and hope something sorta works and go to the Behavioral Clinic and hope something sorta works.
All of this is not to suggest that there is maliciousness among the doctors. It's just to speculate as to why nothing is done about the real problem, and why those suffering from it are shunted into useless and often detrimental treatment pipelines that are blind alleys. The irony is, we probably spend ten times as much treating people with N24 for diseases that they don't have as we would spend studying it to try to untangle an underlying "cause". If there is a cause. I don't think there is necessarily. I think it's normal variation in human function.