LONG LASTING RECURRENT (ATYPICAL?) DEPRESSION WITH TINNITUS IN A
37-YEARS-OLD MAN. ITS IMPROVEMENT WITH ANTISTRESS DRUG THERAPY.
Renato
COCCHI, a neurologist and a medical psychologist.
(An other case with atypical
depression, stress and tinnitus)
Summary.
This
is the report of a 37-years-old man history, who suffered from recurrent
depression since his last 13 years. In spite of current taking paroxetine, he had
a new relapse. He had troubles of the half-brain dominance. Meanwhile, he
started some tinnitus into his left ear. By adding some antistress drugs
(pyridoxine, carbamazepine and oxazepam), after 110 days drug therapy, he
clearly improved the depression, reduced the trouble of half-brain dominance
and decreased the tinnitus of 18.75-27%, as subjectively scored with an
analogical scale.
Key words: Depression, stress, intrusive
thinking, half-brain dominance, tinnitus, drug therapy, glutamine, pyridoxine,
paroxetine, carbamazepine, oxazepam, bromazepam.
Drug modulation of stress reactions
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It came to my observation a long-lasting
depression case with recurrent relapses, in spite of the antidepressant drug
therapy, in a person of 37 years. Recently some one-sided tinnitus appeared.
Since this case has shown unusual evolution, mainly for the tinnitus, I
reported here its case history.
The case history.
June beginning, 2004, first consultation.
Male, of 37 years and 10 months, married, with a child, and an other child in
arrival. Currently he is the managing director of a film company, but he is not
happy of this job. In past he spent some of his life among the Franciscan
monks.
Now, ha refers depression, dissatisfaction,
difficulty of willing. He has a familiarity for the depression in the fatherly
line, and his mother has some depression too. No problems in his fetal life, he
had birth in the 41th week, with a prolonged delivery, and ingestion of
amniotic fluid. He weighed 3730 grams. Not cyanosis, not respiratory distress,
not neonatal pathological jaundice, were reported. In the first year of life he
had heavy sleep troubles.
In adolescent age, he applied very much to
the masturbation [an adrenergic compensation?].
In 1991, he had already a "nervous
breakdown " [a depression] attributed to stress. He took drug therapy, but
after a period of comfort he already had three relapses with intervals of about
18 months between each other. When the depression improves, he would seem to
enter into a hypopomanic state, even if he never got any true manic episode.
Currently, since a year, he is taking paroxetine as drug therapy, a 20mg tablet
every day. However, it did not prevent the actual relapse. He suffered from
panic attacks.
Now, he is smoking 15 cigarettes per day,
and in a recent past even some cigarette of "cannabis indica"
(marijuana). He says that he stopped it because the child and for the next who has
to be born.
Stress symptoms: He suffers from the heat, but by the sea is doing
well off. The wind gives him some irritability. As for sweet things, he has an
increased intake of them and he has normal pleasure for the meat or cube
buillion. Low blood tension and bradycardia are usual [Is it there a vagal
prevalence?]. Now he does not bear both the noise and the confusion. In the
mornings he has not hunger at once.
Symptoms of troubled half-brain
dominance: He refers intrusive
thinking, with an emergency of hostile, bad feelings, bad, with aggressive
"instinctive" ideas (he calls them "the fists") against
beloved persons. Probably he has some mental emergency of recurrent musical
tunes, but he does not remember well.
He denies being a Contrary Mary. To the test
"Which is the opposite of the Red colour?", he answered: Black.
Stress symptoms: He suffers from the heat, but by the sea is doing
well off. The wind gives him some irritability. As for sweet things, he has an
increased intake of them and he has normal pleasure for the meat or cube
buillion. Low blood tension and bradycardia are usual [Is it there a vagal
prevalence?]. Now he does not bear both the noise and the confusion. In the
mornings he has not hunger at once.
Hands' oversweating is modest. When
sleeping, he has no drooling, he does not speak, no nighttime cramps, but
bruxism, and dental shut during the day.
He wakes up tired, and he has poor
strengthes in the morning. In some day is realized of don't pronounce correctly
some words (dyslalias).
Perhaps he has had disbandment feelings, but
surely had feelings of faint. He doesn't have pallor neither eye sockets. He
needs often to urinate.
Other depressive symptoms: Headaches, left sided half-brain type, are rare,
not more than one every second month.
In past he had feelings of mediastinal
oppression, but never of the lump in the throat. Sometimes he has air hunger [a
way for reducing the intercostal muscles' tone?] . He doesn't ever suffer from
tachycardia but extrasystoles that sometimes ago had him even a little worried.
He is doing better in the afternoon, from 18 in then. His hair is fat. Usually
he inclines to get up late.
Tinnitus: Some tinnitus in whistle form is reported into his
left ear, when he smokes and when he is tired. It usually starts at once, just
waked and he feels it in the internal central position. Its intensity is not
excessive, since he does not have difficulty in falling asleep. By using an
analogical scale from 0 to 10 he evaluates it as 8-9. His hearing is normal.
Temptative drug therapy in addition to
the paroxetine 20mg (daily doses, by
the oral via): Pyridoxine 75mg; Carbamazepine 100mg; Oxazepam 15mg.
September 2004, the first checkup after 110
days of drug therapy.
He is doing better, more happy and serene, with
more willingness to do. Now, he is in a clearly modest hypomanic state (some
talkativeness).
He resigned the old job for a new one in the
social and care field.
Stress symptoms: I did not have any more feelings of faint. His
oversweating Increased. Now he bears better both the noise and the confusion.
Perhaps he has less nighttime bruxism, but the daily dental shut unchanged. He
is less asthenic, even to the awakening. The need to go often to urinate
disappeared. Now, at the mornings, he is hungry at once.
Symptoms of troubled half-brain dominance: His head is more clear of intrusive thoughts,
mainly in the morning. Not more bad feelings ( the "fights")
appeared. He had some mental repetition of musical tunes.
Other depressive symptoms: He wakes
up early in the morning. After a "heavy" evening, he had some
symptoms of a panic attack. This happened too after he smoked some marijuana.
Less hunger of air appeared. He felt "itch " of mediastinal
oppression, but fewer extrasystoles. Now he is well doing even in the morning.
His hair is fat as first.
Tinnitus: It reduced. Now he evaluates it 6.5 out of 10 (this
makes a reduction of the 18.75-27%). It starts in late forenoon, every day, and
it increases when he takes coffee, smokes too much, when he is tired, or when
he has eaten heavy foods.
Therapeutic variation (daily doses, by the oral via): Glutamine 125mg:
Carbamazepine 200mg; Bromazepam 1mg. Oxazepam stopped.
Discussion.
The diagnosis of the depressive form of this
subject, according to the DSM-IV, 1994, could be termed Major Depressive
Disorder, Recurrent (F33.1), Full Inter-episodic Recovery. The fact however
that at least the last relapse occurred during paroxetine drug therapy, points
up on a certain atypical feature. On other hand this atypical feature doesn't
correspond to the specific criteria in order to add to the diagnosis "With
Atypical Features". The evidence supporting the current DSM-IV atypical
features criteria, is weak (Benazzi, 2002). Beyond it, monoamine oxidase
inhibitors (MAOIs) may be most effective, but their side effects can be
troublesome. Tricyclics are clearly less effective than MAOIs, but the newer
antidepressant SSRIs (Nelson and McElroy, 2003). The paroxetine taken by this
person is exactly an SSRI drug. Despite the name, atypical depression is
actually the most common subtype, according to Nierenberg and coll., 1998.
The hypomanic aspect, here reported too,
could follow the improvement of the depression, and so it is not unknown.
Perugi and coll., 1998, point up a prevalence of a light manic state
("soft bipolar (II) features") in the atypical depression.
It may be interesting the observation that
the depression has improved without any change of the antidepressant drug
paroxetine, but only adding antistress drugs like carbamazepine, pyridoxine,
and oxazepam.
In the therapy variation following the first
checkup, the antistress action was intensified by adding the glutamine,
increasing the carbamazepine and substituting the oxazepam with the bromazepam,
a benzodiazepine with a longer half-life. The increased carbamazepine could
refrain of a possible manic shift.
The troubles of the half-brain dominance
improved (fewer intrusive thoughts and disappearance of "bad"
feelings against beloved persons).
Very interesting is the result on the
tinnitus, which the patient clearly related to stress situations. After 110
drug therapy days he subjectively scored it as reduced between 18.75 and 27%.
It is not more present since the awakening.
Conclusions.
A 37-years-old man suffering from recurrent
depression since 13 years, in spite the current paroxetine therapy, had a new
relapse. Recently he started to sense a tinnitus into his left ear. The
addition of some antistress drugs to the usual therapy, after 110 days, drove
to a clear improvement. So happined for the depression, with even a reduction
of the half-brain dominance troubles, and decreasing of 18.75-27% of the
tinnitus, as subjectively scored with an analogical scale. This last datum, if
confirmed, could bring to new ideas about the origin of the tinnitus.
References.
American Psychiatric Association. Diagnostic
and statistical manual of mental disorders (4th ed). Washington DC: American
Psychiatric Association, 2000.
Benazzi F. Can only reversed vegetative
symptoms define atypical depression? Eur Arch Psychiatry Clin Neurosci. 2002,
252(6):288-293.
Nelson EB, McElroy SL. Atypical depression:
Piecing together symptoms, treatments; and which antidepressants are most
effective? Current Psychiatry On-line Vol. 2, No. 4 / April 2003.
Nierenberg AA, Alpert JE, Pava J, Rosenbaum
JF, Fava M. Course and treatment of atypical depression. J Clin Psychiatry
1998, 59 (suppl 18): 5-9.
Perugi G, Akiskal HS, Lattanzi L, et al. The
high prevalence of "soft" bipolar (II) features in atypical
depression. Compr Psychiatry 1998, 39: 63-71.
Posted on Internet on the 4th Ottobre
2004. Copyright by Renato Cocchi, 2004.
Corrispondenza: dr Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions
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