Daily Cycle of Symptoms and the Relation to Sleep
The symptoms have a marked circadian (daily) pattern becoming much worse in the evening to early morning and often completely abating in the later morning. When severe, the symptoms will start in the afternoon or even shortly before noon. In some very extreme cases the symptoms occur 24 hours a day, but even then are generally less severe in the morning. In almost all cases, however, there is a relative sparing of the early morning hours from about 7-10 AM, when there are virtually no symptoms. Patients nonetheless live in dread of the next bedtime when they will again be struggling with these feelings. Nighttime brings not rest but suffering.