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Shifted Circadian Rhythm and Treatment

Subjective:

M.M. is a graduate student, with a huge work load but no regular work hours required during the research months. So he ends up going to bed at 5 a.m. and waking up at 11 a.m. every day. He eats dinner at 7 p.m. and feels tired after dinner, but he stays up to get more work done. Then he tries to go to bed at midnight because his body feels tired at that time. He finds that his mind is still going though and so he stays up until 5 a.m. Finally by that time, he is exhausted and goes to bed. The next day at 11 a.m., he wakes up still feeling tired but has to get back to work.

He denies having anxiety when he's trying to sleep. He's not really worrying about things, but just stays up thinking about his research. He doesn't have any problems with sleep once he falls asleep. He doesn't wake up multiple times, have nightmares, or pain preventing him from sleeping.

He would like to live in the world of light rather than be a vampire. And he actually functions better in the mornings anyway. He's not as productive at night. He is just having trouble trying to get back to a normal schedule. He's tried taking melatonin at night to help him get to sleep, but he don't find it helpful. He's also tried going to sleep after dinner, but finds that he just wakes up at 2 a.m., which doesn't break the cycle.

Objective:

He appears healthy overall, in no immediate distress. In our dialogue, he does not appear to be sad or anxious, laughing appropriately, and responding to questions appropriately.

Assessment:

M.M.'s problem is that his circadian rhythm is off. He does not have anxiety, depression, or medical problems causing his insomnia. It is simply that his days and night controls within the brain are off. Those are normally set by the body's production of melatonin a few hours before sleep and the exposure to bright blue light upon waking. The current challenge is to make him sleepy so that he goes to bed at a decent hour and is able to get the 7-8 hours of sleep he needs.

Plan:

I recommended that he do the following. For dinner, eat a light dinner that doesn't have much carbohydrates so he doesn't feel so tired after dinner. At 8 p.m., take 6mg of Melatonin. At 11 p.m., listen to a hypnosis CD, such as the one from Dr. Gurgevich. He should be able to sleep well then. At 7 a.m., wake up and go outside for a while to get the morning sun. No naps during the day.

Repeat for 3 nights. That should help get him back on schedule.

After that, melatonin should not be necessary anymore.

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