A FIFTH CASE OF ATYPICAL DEPRESSION,
RECURRENT, WITH THE ALTERED EEG (POSSIBLE EPILEPTIC DEPRESSION) IN A WOMAN OF
44 YEARS AT THE FIRST CONSULTATION.
Renato Cocchi, a neurologist and a medical
psychologist.
Summary.
A woman of 44 years at the first
consultation in 1998, born following a delivery with the forceps, had recurrent
episodes of atypical depression, sometimes with phobic features.
An EEG scan after one year of drug therapy
showed aspecific anomalies (sharp waves, bilaterally, but primarily in the left
half-brain that involved the frontal-temporal and middle temporal areas. Four
years later since the beginning of the drug therapy, now mainly antidepressant,
and antistress, this woman goes on to have a relapse every one-two years, after
a period of well-being and therapy non stopped. The case drives to think to a
like-epileptic phenomenon with pure psychic expression (a possible epileptic
depression).
Key words: Atypical depression, nosophobia,
stress, epilepsy, EEG, sharp waves, epileptic depression, drug therapy,
amitriptyline, carbamazepine, benzodiazepine.
Drug modulation of stress reactions
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After I published four cases of recurrent
atypical depression as possible epileptic depression (Cocchi 2004; Cocchi 2004;
Cocchi, 2005; Cocchi 2005), a recent checkup (on February 2005) permitted me to
find a new case in a patient of 44 years at the first consultation whom I
followed since March 2001.
It is a new case that deserves a report
because its depressive specificity and EEG alterations. These last ones seemed
me an addition and not, as I think now, the starting point, when I examined the
results of the EEG. To having reported it here, as it follows, makes it the
fifth case of what appears as a little series.
The case history.
March 2001, the first consultation. A woman
of 44 years, depressed and in drug therapy since over 20 years. She is taking
amitriptyline + chlordiazepoxide, and lorazepam.
Always dissatisfied, but currently she
doesn't cry. Often she has sudden vertigoes, with open eyes, but she doesn't
see the things that turn around her. She has unsteadiness (subjective
vertigoes). At times, she is suddenly feeling of her head confused and stupid,
a long lasting sensation. Then she tells that she thinks too much on many things
(fluctuating intrusive thought?), and she has anxiety in her stomach
(mediastinal oppression). In the morning, she is doing better. After leaving
her bed, she is hungry nearly at once.
When she resumes her work in the afternoon,
she has immediately anxiety. When she sleeps a few in the afternoon, she wakes
up with a start. At night usually she sleeps. She has diurnal bruxism.
She doesn't have muscular cramps at night,
but has them daily, at the cemetery, when she descends the staircases [??].
During the sleep no drooling occurs. She leaves the bed as tired. When in
company of other persons she is well. Now, she is afraid of becoming sick. She
has fainting feelings.
When she becomes anxious has more need to
empty her bowel. Her menses did not stop, but the cycle is short. Usually she
suffers from cold. As for sweet things, she is a little greedy of candies, and
she likes the meat or the cube broth. Her diet is not correct. Her hair is fat.
At times she has sudden memory of losses (for the Ave Maria, as for an
example). No intolerance for light, noise or confusion occurs, but frequent
tachycardia.
As she was told, she is born with forceps
and in her first year of life she had problems for feeding.
Test therapy (daily doses, by the oral via):
Glutamine 125mg; Thiamine 62.5mg + pyridoxine 62.5mg + cyanocobalamin 0.250mg;
Tetrahydrofolates 7.5mg; Carbamazepine 200mg; Amitriptyline 10mg + perphenazine
2mg; Bromazepam 1.5mg.
April 2001, the first checkup after 35 days
of drug therapy. She is little better, but she still has her head confused and
sudden unsteadiness. The anxiety diminished, but she still feels tachycardia,
although less of frequent. In the afternoon she does not succeed to sleep and
she has start awakenings. Often she has bad dreams. The vertigoes diminished.
The episode of confused head lasts less. Her head is less blocked by thoughts.
Now, the mediastinal oppression reduced. She has the impression of breathing
badly. In the afternoon, when she has to resume her work, now she does not
become anxious as previously. She always fears to feel badly. In the morning
she leaves her bed less tired. Her appetite increased a few.
Therapeutic variation (daily doses, by the
oral via): Carbamazepine 300mg; A soluble compound of iron x 10 days;
Bromazepam 2.75 mg.
End March 2002, the second checkup. She did
well till the end November 2001. Then she took some pills prescribed by a
dietician, and she felt badly. Since one month she is little worse. Mediastinal
oppression occurs as well as difficulty to swallow and to breathe. Air hunger
and drowsiness happens. The feeling of a lump in the throat is coming out even
at night, or in the evening, during the supper. She had again subjective
vertigoes. Rarely her head is confused. She is not so much anxious and bruxism
disappeared, but she has always fear of becoming ill. Now, she gets up less
tired. Her work is running well, and she bears more the confusion. The ugly
dreams became rare. I prescribed an EEG examination.
Current therapy (daily doses, by the oral
via): Glutamine 125mg; Pyridoxine 75mg; Carbamazepine 300mg; Amitriptyline 10mg
+ perphenazine 2mg; Bromazepam 1.5 mg.
Beginning April 2002, the EEG examination.
Report: The EEG was acted in conditions of psychosensory rest. It recorded a
basic rhythm alpha of 9-11 Hz, of the middle voltage, normally spread,
symmetrical, with irregular morphology, with valid reaction of the stop.
There are even rare paroxysms of sharp waves
of middle voltage on the frontal-temporal and middle temporal regions with
inconstant left prevalence. The hyperpnea strikes slightly such anomalies. The
intermittent light stimulation doesn't produce variations.
Conclusions: Modest sharp waves anomalies on
the frontal-temporal regions and middle temporal regions.
** Having had the chance of personally
evaluating that EEG on February 2005, I found that the alpha rhythm, in the
frontal regions, superimposes on theta sequences, with prevalence to the left
half-brain. R.C. **
Half February 2005, the third checkup. She
always took the drug therapy. Till October 2004 she did well, then there was a
progressive worsening till the need of revising the therapy. Now, she is
sleeping badly with many awakenings, but without the need to go to the bathroom
to urinate. In the morning, she feels tired. She is afraid of going to rest in
the afternoon, because of frequent starts. The lump in the throat came out
again, and the nose closes. The subjective vertigoes reappeared, now as
frequent. In her work environment, she feels badly, without any reason. When she
is going to her workplace, she has panic attacks. She has sudden fits of
mediastinal tension. Since she takes a drug therapy against the hypertension,
she is doing better. The tachycardia is however rare. She says that she has
difficulties to sleep laying on her back. Now, she fears anything, mainly
illnesses. Ugly dreams reappeared.
Therapeutic variation (daily doses, by the
oral via): Glutamine and Amitriptyline + perphenazine stopped. I prescribed
Pyridoxine 75mg; Carbamazepina 300mg; Amitriptyline 6mg; Lorazepam 1mg;
S-adenosil-l-methionine 200mg.
Discussion.
It is again an atypical depression,
recurrent since nearly 25 years.
Even for this patient I have first to
remember, the features of the preceding cases, that however are not fully
superimposable.
1. Perhaps here too we may speak of a
modest, if not poor response to the serototoninergic drugs, tricyclici and
SSRIs, because these were already used alone, or with a benzodiazepine;
2. The change of the mood is recurrent but
not fitting, and it can be such longly, for weeks or months. The surely fitting
symptoms here are the mediastinal oppression, the confused head, the sudden
loss of memory, even for a well known prayer, learned and repeated since the
infancy such as the Ave Maria;
3. It is the same the lack of a some
relationship with external causes clearly identifiable;
4. It is also the same the altered EEG, but
not meaningful for epilepsy;
5. It is similar the good response to the antiepileptic
and antistress drugs, but it is not a stable response.
6. I did not observe any positive variation
of the personality following this therapy, otherwise other cases (Cocchi 2004;
Cocchi 2004; Cocchi 2005 ), but, on the contrary, it seems to heve been a
worsening of the fear of illnesses (nosophobia).
As for alterations of the EEG rhythm,
independently from the theta sequences I have seen in the EEG of this patient,
in it, as in the other four preceding cases ( Cocchi 2004; Cocchi 2004; Cocchi,
2005; Cocchi 2005 ), those have always place also in the temporal zones. At
this stage I need to remember what Matarazzo wrote in 1976, by stating that in
these chronic depression forms the temporal lobe is involved. There is not
doubtful that a depression lasting since nearly 25 years is a chronic
depression.
The starting point of these EEG anomalies,
usually said as "irritating," in this woman could be found again in
her birth with the forceps. This is a very well known risk factor for more
burden outcomes too, like cerebral palsies, epilepsy and mental retardation.
Conclusions.
I am always more convinced of the existence
of atypical depressions that have their ground in a trouble of the EEG rhythm,
as a signal of brain suffering in the past. Here was a fetal extraction with
the forceps, a well-known risk factor. In the preceding cases, in three out of
four there were complications of the delivery and a meningitis at five years in
the remaining one. The actual trouble, in this patient, is expressed in purely
psychic forms, mainly depressive, with phobic features.
References.
Cocchi R. An atypical depression with an
altered EEG (epileptic depression?) and his evident improvement with
antiepileptic and antistress drug therapy. 2004 <www.stress-cocchi.net/Depression6.htm>
Cocchi R. A second case of recurrent
atypical depression with an altered EEG (epileptic depression?) in a 27-years
old man. 2004 <www.stress-cocchi.net/Depression7.htm>.
Cocchi R. A third case of recurrent atypical
depression with altered EEG (a probable epileptic depression) in a woman of 22
years at the first consultation.
2005<www.stress-cocchi.net/Depression8.htm>.
Cocchi R. A fourth case of recurrent atypical
depression, with derealisation phenomena, with altered EEG (a probable
epileptic depression) in a woman of 36 years at the first consultation. 2005
<www.stress-cocchi.net/Depression9.htm>.
Matarazzo EB. [Chronic depression and
temporal lobe dysrhythmia] : Arq Neuropsiquiatr. 1976, 34: 173-187. (In
Portoguese, quoted by Medline).
Posted on internet on 4 March 2005.
Copyright by Renato Cocchi, 2004.
Author's address: Dr Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia