Dr. Amy Nett: Yeah, that’s generally what I would consider circadian rhythm disruption. I like to put it together a little bit with the clinical picture and I tend to ask patients, hey, how do you feel in the afternoon? And they wait to see if it matches with what their graph looks like. But yeah, anytime you see that patient line, I think it’s the red line that goes outside of the reference range lines, which I believe were the black lines, then I think about cortisol’s out of range at that point. So I might consider it a disruption. That said, if it’s just an elevation—let’s say there’s an elevation at that morning level and it’s just a higher peak than normal—I don’t know that I would actually call that a rhythm disturbance. I would probably just call that, it depends on what the total cortisol looks like, but I might say something like, “Oh, you have hypercortisolism in the morning,” something like that, and be a little bit more specific. To me a disruption or circadian rhythm disturbance more often if it doesn’t match the normal curve.
So if it goes out of range you might consider that a disturbance, but it’s more when it loses the normal pattern where we see it rising in the morning and then decreasing afternoon and before you go to bed. So I try to be as descriptive as possible with patients and you can certainly lump a few different curves under a “circadian rhythm disruption,” but I’ll try to be descriptive, and I may just say, “Oh, you have high morning free cortisol, otherwise normal production or you have low afternoon cortisol.” So I think you have some flexibility in what you want to call it and then in that particular case, oh, you’re not referring to a particular case that I see. But yeah there will be times when I’ll probably call it a circadian rhythm disruption. But there’s some flexibility there.