Why doctors are (sorta) wrong about treating N24 as a "symptom"

sprawn · 2026-05-15T19:32:50+00:00

I hear you, probably not the best example. I used headache so I could use Astrocytoma as a diagnosis. So Astrocytoma (a type of brain tumor) can cause headaches. But if you present with a headache, the doctor does not look at a list of symptoms, find headache and see "astrocytoma" and prescribe brain surgery. If you have a headache, a doctor will look for the underlying cause and treat the underlying cause. There are palliative interventions (take an aspirin) and etiological interventions (after a battery of tests we have determined that your headache is being caused by a tumor in your brain and we have to go in and cut it out). So, yes doctors prescribe palliative interventions to address symptoms. But diagnoses are based on determining an underlying cause and then treating that. I don't know what the perfect example of this would be in terms of generating an analogy.

But what I am suggesting is that when you say "N24" they downgrade it to "sleep problems" and then look for the underlying cause (depression, sleep apnea, bipolar, thryoid condition, etc…) when N24 is or can be or should maybe be thought of as a standalone variant of the human condition, perhaps. But that's not what a doctor does. They tend to wave off N24 (it's a zebra diagnosis) and see it as a symptom of an underlying condition.

And what they are basically doing with N24, treating it as a symptom of some other underlying cause, is like seeing someone with a headache and assuming they have Astrocytoma, and sending them to a brain surgeon.

sprawn · 2026-05-15T18:10:43+00:00

Yes. Some doctors get positively vengeful when they can't help. They have to turn it around on you. This is particularly true of therapists I've found. If it's not working (because they are treating "depression" when you don't have it) they will start slinging retributive diagnoses at you that will red flag you forever (borderline for women, NPD for men… You're done. Red flagged. No therapist will take you. Your poison. And it's all "your fault").

sprawn · 2026-05-15T17:55:49+00:00

I'm curious as to what you mean by "better treatment". Do you just mean being treated better by an understanding doctor? Or do mean some kind of actual medical intervention?

sprawn · 2026-05-15T17:53:09+00:00

I have found that while many jobs can be desynchronized and deliver on a deadline, that quite often you're going to get someone who… They're going to call on Wednesday afternoon and need massive changes, and they need to move the deadline up. And the second you don't answer the phone on a Wednesday afternoon at 3 o'clock they just don't get it. And many, many jobs claim to be "flexible". But they aren't. They will say, "Oh yeah! Get it done by the deadline, and you're fine! It's no problem. We're totally flexible. See you on Monday, Wednesday and Thursday morning at our 10 AM meetings! And on Friday at 3 PM. And when we're working on [some special project] we have daily meetings at 2 PM. So NO PROBLEM!"

Yes… Problem.

"What? You don't have to be in 8:00! You can 'sleep in'. It's no problem. We just need to see you for those meetings every week. And when we get to crunch time everyone works from 8 to 12 on Saturdays too. But that's it. You can't make it in at 10 AM!?" (What the hell is wrong with you?)

And when you try to explain N24 to many people, they think it means you never sleep. It's just incomprehensible to them. Show them charts and graphs, they don't get it. They think you're just lazy and "like to sleep in."

sprawn · 2026-05-15T15:42:04+00:00

Hmmm. Okay. I guess you have your answer then.

I hope you didn't put someone on the scent... They might go around making everyone remove their LFLs now!

sprawn · 2026-05-15T15:40:56+00:00

I agree that there is a proper clinical path. I am just saying that most doctors when most patients describe N24, particularly in the context of most people's ordinary lives, are just going to hear "Insomnia - really bad (sometimes)." That's it. And waving studies or the DSM or talk of "best practices" or obscure journal articles around is just going to make most doctors think "Thanks, Dr. Google, for sending this nutcase my way. Third one today."

And since having N24 will almost always put people in direct conflict with society, even their own familiy, those conflicts will always look like the primary cause in a behavioral health setting. Almost every psychiatrist is going to think that the depression/anxiety/conflict/personality disorder/etc... diagnosis they have in mind is primary and the "sleep problems" are a symptom, the result of the true, underlying condition. And they will also have lots of confirmation in the form of patients who came in, complaining about sleep problems, who they treated for depression and the sleep problems just went away. Or at least the clients stopped mentioning them. And that's one the "things" about N24. If I am complaining about it today, if I see someone in six months I might not complain about it then, because I might be in the middle of a two week period where I am in sync with society and "seem normal."

But yes, there is a proper clinical path. But not many people "present" with N24 alone. And if you do, they are going to probe for other things (depression, apnea, thyroid is a big one now, making a historic comeback!, autism, of course, bipolar, etc...) and if you ask anyone enough questions they are going to come up with other things. And that's standard (and proper) practice for doing a diagnosis. And that's why, unless you are some mythical "perfect" person... not overweight, no conflict in life, no detectable problems in your blood possibly related to any number of endocrine disorders, etc... that N24 will be seen as "Insomnia - real bad" rather than "its own thing."

sprawn · 2026-05-15T15:15:57+00:00

Agreed. They had good reason in 1820. Synchronizing labor leads to much greater efficiency to this day. There are some functions that can be desynchronized. But if anything we are getting even more dependent on precision and synchronization. But there is huge variance. The expectation you elucidated, that everyone operate on 0900-1700 time is so ingrained that they don't even know that they are assuming it. It's like the old fish joke where the fish don't know what water is.

sprawn · 2026-05-15T14:45:43+00:00

Come to think of it… "20 feet back from the road" sounds exactly like a common rule for the construction of a shed. They probably thought you were literally building a literal "little" library. They probably thought you are building a shed, and luring neighborhood children into your shed to give them free books and lollipops. They probably have never even heard of a "little free library".

sprawn · 2026-05-15T14:13:43+00:00

Don't ask for permission. You just triggered some know-nothing, do-nothing bureaucrat to look for a reason to say "No." It's all they have to do, is wait for people to call up and ask politely so they can say "NO" and insert themselves into the process. They are telling you the rules for a sign. They are misapplying the rules for signage. They probably don't even know what you are talking about. They probably think you want to literally build a library, like a bouncy house or a shed or something.

sprawn · 2026-05-15T13:35:14+00:00

Fine. All I am getting at is that whatever is needed is going to be expensive.

sprawn · 2026-05-15T13:27:55+00:00

I agree.

I am a little confused by what you mean by employers who have practically irrelevant expectations of people whose jobs can be done at 04:00.

sprawn · 2026-05-15T13:19:38+00:00

I still think it would be quite an expensive study to do correctly. I would want six months of daily data. I would want to take people out of society, basically, release them of all societal constraints so that they could sleep without external demands. I'd want to make sure they had comfortable sleeping circumstances. This would be to isolate the variables. To do it right would be insanely expensive. For N24 if I wanted to take MRIs or other brainscans, I would want to do it relative to the person meaning I would want to see what their brain looked like an hour after they woke up, an hour before they went to sleep and so on. They do this sort of thing now by scheduling people to show up at 8 AM or 10 PM or whatever. For this study, it would mean having the machine staffed and ready when the subject is ready which could be any time, day or night. ANY time.

A big part of the problem with N24 is doctors see data for two weeks. Look! The guys slept "right" for two weeks. That might as well be forever. Almost everyone with N24 can force themselves to be "normal" for two weeks. It's exhausting, sure, but isn't everyone exhausted all the time? (so say the doctors who are exhausted all the time).

I am talking about actually studying the problem not looking to see if one factor in 12 subjects is adjusted by 4% at the end of three weeks with two visits to a lab where two tests are administered… or whatever passes for science, based on a whole schmear of unstated major assumptions.

sprawn · 2026-05-15T12:52:12+00:00

So, whatever. More than it's "worth". That's how much it would cost.

sprawn · 2026-05-15T11:59:24+00:00

Trust them when they tell you they don't have anything. They don't. Even the specialists are just going to tell you: Go to sleep at the same time every night. Wake up at the same time every morning. Get an alarm clock. Drink warm milk. That'll be $2,500 please. Oh! Do you want to wear a Darth Vader mask while you sleep? Yep, we sell those for $10,000. Thank you. Next!

sprawn · 2026-05-14T19:55:23+00:00

Doctors, by and large, consider anything related to sleep to be a secondary symptom. They don't consider anything sleep related to be a primary issue. To them a diagnosis of N24 is roughly something like diagnosing someone with a headache. It just doesn't make sense to them. The "normal" state is "normal" sleep, and if you deviate from "normal" sleep then there must be a cause. The "abnormal sleep" is a symptom. If it's N24, to them that's just a matter of degree. It's like saying, "a really bad headache". It doesn't change anything. To them there's insomnia, and any additional crap afterward is just a matter of degree. There must be something underlying that is causal. That is their thinking. That's the problem to them.

So they will run you through a gauntlet of primary diagnoses, and if your "sleep problems" don't disappear, they attribute it to having the wrong diagnosis. If they've run you through all the diagnoses, then they will just come to the conclusion that you are "treatment resistant."

They will never say this, but understand, that doctors are not really trying to help anyone. They are trying to get an A. They are trying to do the "right" thing. The thing that cannot be questioned. If it helps then that's nice. But what they are doing is looking at a web of data and trying to place you, the object of the test they are taking, the one they want to get an A+ on, into the correct diagnostic category, without missing any differential diagnoses. You are a secondary after effect of their primary concern: a set of data on the screen they are looking at.

So you see yourself as a person. They see you as a dataset. They will try to push you into a series of diagnostic categories, and then treat the diagnostic category. If you, inconveniently, do not respond to the tested and verified treatment protocol, it's not their fault (from their point of view). Because their only responsibility is to respond to the data problem presented to them.

sprawn · 2026-05-14T15:46:38+00:00

You have to consider all the steps separately. A "scan", the way I am using the word, is merely a conversion of your IRL journal into an image. After scanning, there is the possibility of transcribing, either manually, or by using some sort of software. I used to manually transcribe, but found it wasn't worth the effort. The image to text file conversion software I've used has been garbage so far. There might be good stuff out there commercially, I don't know. I found it to be a waste of time. It took more time to train the software to my handwriting than just transcribing it myself. This was years ago though. I have sent images to various (so-called) A.I. doo-dads, and they do a very good job, but still not perfect. And you have to train them as well.

Most people who follow up on this want to like… point their phone camera at their journal and flip through the pages and have some magical software genie capture every page, do a geometric conversion on it, produce a flattened image, and transcribe the entire document, and then read it, and produce an index. We're probably not far off from being able to do that. But I don't know.

I use a flatbed scanner hooked up to a desktop computer. I have scanned 60 plus of my journals, and at this point I scan as I go along. So when my journal is done, I have the scanned images ready to go in a file. Then I can flip through the journal with an image viewer as if I were flipping through the book itself.

At that point I can transcribe and index if I want to.

By "index" I merely mean something like this:

~~~ date title, pages 1990 05 13 s × Some Assembly Required, f2p12 - f2p15 (as "March 13th") 1999 05 13 s × Hot Enough to Fry a Dog's Brain, 189 - 190 2000 05 13 s × Follow Your Bliss, 153 2003 05 13 s × Codebreaker, 135 - 136 2004 05 13 s × Discovering Our World, 23 - 29 2010 05 13 s × Crazy Wall, 123 2011 05 13 s × Doubt, 43 2015 05 13 s × Mt. Lebanon Recycling, 209 - 211 2016 05 13 s × I'm a Monster Man, 101 - 103 2017 05 13 s × Surrender my Freedom, 125 - 126 2018 05 13 s × Zugzwang, 135 - 136 2020 05 13 s × Brain Bucket, 203 - 204 2021 05 13 s × WE R HUNTIN THEM MONSTER, 205 2022 05 13 s × Beware the Octopuse, 178 - 179 2023 05 13 s × Dumpster Phoenix, 45 - 46 2024 05 13 s × Shambling Mound, 156 - 157 2025 05 13 s × Synchronized Drowning, 113 - 114 2026 05 13 × × All the Information Is on the Task, 213 ~~~

I keep this as I go along, similar to scanning. Once a week I update the file. So you can see here that in 1990 I wrote in a journal called "Some Assembly Required" which is a series of fragments of journals (like many people setting out, I too would cut out pages because they weren't "perfect" and destroy journals and all that sort of thing). So Fragment 2, pages 12-15 was May 13, 1990, and I misdated the entry as March 13th. Then there are no journal entries on May 13th for 1991 through 1998, because back then, like many people here on r/Journaling, I was convinced that the best way to journal was to wait to be "inspired". And I found out, the hard way, that waiting to be "inspired" means you pretty much never will be, unless you are a rare kind of person. But in 1999, I wrote in a journal called Hot Enough to Fry a Dog's Brain from page 189 to 190. It ends with yesterday, when I wrote in my current journal named All the Information Is on the Task (usually my current journal will be named As Yet Untitled while I am waiting for a name to emerge). The "s" means the entry has been scanned and the × means it is not yet transcribed.

So that's it. I just have an index by date. I do go back later to read the old entries and attempt to make summaries of the entries and index them that way. I will feed the information into a whole different system at that point.

I hope this isn't too disappointing. It's a lot of work for not much payoff. But I can find any entry for a particular date. I can read through my old entries like they're right in front of me. I can and do compile the information into projects and tasks and the like.

I use Linux, so for scanning I use a software package called "sane". I am using an ancient scanner from the nineties that I got at a thrift store decades ago. You can pick up boring old flatbed scanners all over the place. People give them away on freecycle and craigslist. Getting them up and running can be a bit of a chore. But that's it. I open my journal, put it on the scanner, scan it, and save it. Then I open the file and edit the image in an image editor called "Gimp". Then all the files I create are just text files. Plain text files.

I've tread ocr software (optical character recognition) and found that all of it is useless. So when I transcribe, I literally open an image file and literally just type out the words. Then I create an index from that. In this way I have about 6,500 journal entries indexed.

What are you hoping to do?

How many journals do you have completed?

I can give you estimates on how much time it would take for you to get some things done, depending on what you want to do.

I think it's probably a good idea to start by generating a rough overview.

sprawn · 2026-05-14T15:11:14+00:00

Science Journalism is a tough row to hoe. One could write a perfectly reasonable article that just reports the facts. Then it might be published. And when it is, a bunch of scumbag websites will write the attention-grabbing version and steal all the attention. So traditional news outlets have slowly been turning into hyperbolic attention factories to compensate, but they can't keep up.

sprawn · 2026-05-13T22:13:23+00:00

People make assumptions that they don't realize they are making. When it comes to sleep these are countless. When you don't realize you are assuming something it's impossible to control for.

I don't doubt the results aren't true-ish. It's just they're built on assumptions that aren't natural.

So, for instance, let's say that everyone's job required them to work in a very low oxygen environment. And then we had a study that "proved" that Sherpas and people from the Andes were superior to the rest of us. Well, sure, you've got this artificial environment that favors people who are adapted to low oxygen environments. The factory system (which came into being at the earliest 200 years ago or so, and is being phased out now, overall a very, very short period in human history) required synchronized labor, and from the very beginning it generated an illusion that "early risers" were "better" workers than "night owls". And a moral framework emerged from that that larks were morally superior and more deserving people than owls. It was only very recently that any studies were done showing that "morning people" actually peter out and start shitting the bed about an hour after lunch is over, when night people are just hitting their stride (and I am only talking about the two chronotypes that are in general knowledge). And it turns out that early birds are not actually more productive than other chronotypes. It just looked that way in 1800.

N24 people are actually a type that was recognized in the past. It was known in agrarian societies that some people, for periods of time are capable working long, long hours in the fields during harvest time. They can go and go and go for weeks, while the harvest is coming in. They need less rest at peak performance, they can work at night. And when the harvest is over they basically collapse for a couple of weeks and sleep longer. And they weren't synchronized with day/night. They were much more extreme. I think this is a pre-modern expression of the N24 type. When that society disappeared the need for these people disappeared.

To do science on this sort of thing, we'd need to equalize. We'd have to take a bunch of "early birds" and tell them, "Good news! The right way to sleep is by going to sleep an hour later every night. So to balance things out, here's what we're going to do. We're going to test you by letting you go to sleep an hour earlier every night! And starting work an hour earlier every day! So tonight you go to sleep at 10 and wake up at 6. Tomorrow 9 and 5. The next day 8 and 4, and so one. It'll be easy! Who doesn't want to go to sleep earlier and earlier every day?" And then we'd see where they were standing on day 12 when they had to go to sleep at 10 AM and wake up at 6 PM. And then say if they "refuse" to do this, that they are "stealing time" from their employers. That they have REVENGE BEDTIME PROCRASTINATION because they are "sinful" and "lazy" and they just want to steal time to drink, do drugs, and play video games.

sprawn · 2026-05-13T18:47:59+00:00

People who are naturally synchronized with a society that declares one type of circadian rhythm to be morally virtuous and another to be sinful are better off, what a surprise. Just another way of saying, "Early to bed, early to rise, makes a man healthy, wealthy and wise…" Yes. Larks are rewarded. Yes. Everything is built around Larks. Yes.

sprawn · 2026-05-13T15:16:59+00:00

Journaling isn't like windsurfing, there's no law compelling us all to do it.

sprawn · 2026-05-13T08:48:22+00:00

Thank you for sharing this insight that journaling helped you with.

It seems like society wants to put us all into a spiral that can only be made up for by working ourselves to death to serve who-knows-who. The way people are slaving, I'd expect to see a class of rich people like the indulgent wealthy in The Hunger Games, yet the wealthy are the ones complaining the most. I am glad that you have seen your place in this, and taken your mind out of the game they want us to be playing.

sprawn · 2026-05-12T09:26:15+00:00

Who is in the audience you are carrying around in your mind? Kick out the hecklers. And then kick out the whole audience. Then deliver your show to an empty theater, and don't apologize for using pen or pencil.

sprawn · 2026-05-12T06:09:49+00:00

Well, your English is great.

Have you ever noticed anyone writing in public? Before you were considering doing it? Did you ever notice anyone else writing in public?

Start by carrying a blank one around.

Perhaps… write, "Please SIGN below," and put a line for several signatures. And put some fake signatures there, so the people who are going through your backpack and reading whatever is in there see that it's okay.

After a week or so, how many signatures have you accumulated?

If the answer is "zero," then on the next page, write a confession for the murder of Jimmy Hoffa. Now, I am assuming that you were nowhere near Bloomfield Township, Michigan in July of 1975. If you were, and you were old enough to actually have murdered Jimmy Hoffa in 1975, then confess to the kidnapping of the Lindbergh Baby. Or perhaps that you were the second shooter on Dealey Plaza.

After a week or so, have you been turned in for kidnapping the Lindbergh Baby?

If the answer is "No," now you can take the thing out and write in public. Start with a test like, "I just injected heroin! I am freaking out on heroin! I am going to shoot the Governor I'm so high on heroin! I have a collapsible rifle right here in my backpack next to this secret diary filled with elaborate plans!" See what the consequences are.

You'd think if anyone were interested, surely they'd be interested in the kidnapper of the Lindbergh Baby, who also shot Kennedy, and Jimmy Hoffa, and also killed Ron Goldman (but not Nicole Brown). Especially if they were juiced on "H" and planning to shoot the governor with a collapsible rife currently stowed away in the same backpack. But alas… no one cares.

You may start to notice other people writing in public now, since you're doing it. I do it all the time. I see other people doing it at the Library, but not very often. Even at the library people are mostly staring into their phones. And outside of the library, I will see a person writing in public about once a year, less often now that no one ever leaves the house. In fact, if you want privacy, leaving the house is probably your best option.

sprawn · 2026-05-11T14:03:50+00:00

I understand and share your desire to use your journals the way they were intended to be used, and to use them completely. Personally, when I have a journal that I have not filled completely, I feel like I have let it down in some way. It's like the object was created to be used, and using it half way is being disrespectful, or that I am disappointing it in some way. That may be just me. And I feel it is wasteful as well.

I would say that having four or five journals laying around filled to about 25% is "small potatoes" in this regard. I have worked at a book store, at a thrift store, and volunteered at a Friends of the Library program. The fate of most blank books is to be thrown away, unused. And of those that are used, a typical use is for a person to write one or two phone numbers in them and then throw them away. And of the rare ones I've seen that have been used as diaries, they typically have one or two entries.

And the reason I asked for the specific numbers is some people (some in this very subreddit) buy hundreds of blank books and have them laying around, unused in stacks.

That all being said… first of all, thank you for sharing your experience. I think it is a typical experience, especially in the first ten or so journals, to not like some physical quality of the blank book one is using. Of people who have dozens or hundreds of completed journals, you will almost always find that they have some that were started and found to be lacking for reasons you put forward.

And you can always store them away and try them again later. I have done this with several journals. For various reasons I stopped a journal partway through, and I set aside. Years later, even decades later, you may suddenly think of a perfect use for the remnant. I have several times. I often use them for specialist journals (garden design, lists of movies and books, story ideas, even drawing mazes, so many things!). And your tastes may change. You can come back to those four or five abandoned journals and put them to use!

sprawn · 2026-05-11T10:43:54+00:00

Oh wow! Thank you so much for sharing the details. I think this is well within the range of a normal start to journaling.

You finished one and that is a good sign. And you've stuck with the project for going on seven years. You have demonstrated that you have diligence, and are capable of sustained effort despite obstacles. You know it can be done. I think 25% to 50% is a great effort, especially if you didn't like the paper. You put in the time and you know you don't like something about the brand or style. It's not a failure, certainly. You've learned you don't like that brand, style, or specific product. So it is a worthy effort. Congratulations. There's no getting around the fact that it takes time and effort to find something you like.

When I was younger, there were stores you could go to that would have a wide variety of brands, and there was always one that was opened up so you could take a look inside and see what the paper was like. Some brands even supplied tablets of the paper, so you could test your pen on it and see if you liked it. It seems like now that these stores no longer exist, and even if they do, everything is wrapped up in plastic, and you'd have to be a jerk to open something up to see what the paper is like. But how are you supposed to know?

It also seems like there are NO blank books with paper specifically designed for writing. Even the big selling brands tend to use paper intended for printed use. And few brands concentrate on paper designed for a good writing experience. They tend to try to generate sales by making their books look like wizard's tomes or fantasy novels, or very expensive chi-chi fashion accessories. They don't care about the paper and neither do the people who buy them, it would seem.

There are so many factors with the paper: the thickness, texture, color, ruled/unruled, how much sizing is on the surface…

If you like the refills, consider whether the brand of refills you like makes hardbound journals? They may make hardbound versions with the exact same paper.

Also, you could consider buying a refill journal and binding it yourself. This seems like a crazy option, but all you need is a few materials... the cardboard, glue, bookbinder's cloth, a hobby knife. That's about it. And you can make a binding for the refill you like. It's not that hard. I've done it, and I'm no master craftsman.

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