AN EPILEPTIC DEPRESSION,
WITH HALF-BRAIN DOMINANCE TROUBLES, ALREADY DIAGNOSED AS RECURRENT ATYPICAL
DEPRESSION, IN A YOUNG WOMAN OF 26 YEARS AT THE FIRST CONSULTATION. THE REPORT
OF 6 YEARS OF ANTIEPILEPTIC, ANTIDEPRESSANT AND ANTISTRESS DRUG THERAPY.
Renato Cocchi, a neurologist and a medical
psychologist
Summary.
A young woman of 26 years at the first
examination, with the initial diagnosis of recurrent atypical depression, and
problems of half-brain dominance, had a follow-up of six years. She took
antistress, antiepileptic and antidepressant drug therapy, (that included carbamazepine,
a benzodiazepine and an antidepressant drug). The last EEG check led to the
definitive diagnosis of "epileptic depression", even on the ground of
the two preceding EEG examinations. Such a diagnosis was only suggested in the
5 cases previously reported. The EEG troubles, mainly in right temporal areas,
are in a brain section already known to go with epileptic episodes with motor
and psychic symptoms. So, the fact that a partial epileptic form may manifest
exclusively (or about exclusively) with psychic symptoms, it has not to then
amaze.
Key words: Atypical recurrent depression,
epileptic depression, EEG, brain, temporal area, half-brain dominance, stress,
antidepressant drugs, antiepileptic drugs, case report
Drug modulation of stress reactions
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On the request of a colleague, in 1999 I had
at consultation a young woman suffering from a decidedly atypical depression,
recurrent, already followed from other psychiatrists, with poor results.
I report here the follow-up till the last
checkup done in February 2005, because then my prescription of another EEG
control, performed, let me soundly to give the diagnosis of "epileptic
depression."
In the five preceding cases (Cocchi, 2004a;
Cocchi 2004b; Cocchi 2005c; Cocchi 2005d and Cocchi 2005e) such a diagnosis was
always a doubtful one, even if that uncertainty was progressively reduced. In
this sixth case I cannot define otherwise this type of depression.
The case history.
A young woman of 26 years to the first
examination, unmarried, not engaged, is a firm secretary. She is living with
her mother, a widow, and a younger sister. As depressed, she has a current drug
therapy with citalopram and diazepam.
July 1999, the first consultation. Since
years she is suffering from recurrent depression, resistant to the common
therapies with antidepressant drugs and benzodiazepines. Even the attempt to
add a low dose neuroleptic did not vary the outcome. She is working as a clerk
and stays alone all the working time.
Depression symptoms: She often cries, has a lump in the throat, an internal
tremor and tachycardia. Recently both her grandmothers died and, moreover, she
had two great emotional disappointments and now she feels much as alone. To the
Test: "Which is the opposite of the colour Red?", she answers: Black.
A frontal headache occurs. She uses her mother and her sister to complain
heavily about her condition. She was giving psychotherapy.
Symptoms of unstable half-brain
dominance: She's always
dissatisfied. When she has to take a decision that concerns herself, she has to
think much about, but when she just decides in a direction, it seems her at
once that the skipped alternative would have been better. She thinks too much
[intrusive thinking], and in a not constructive way. As for the university, she
dropped out it, without sustaining any examination. She is afraid of becoming
crazy.
Stress symptoms. She has panic attacks. She is always suffering with
the cold, and she is feeling cooled in all her body. Often she is afraid of
fainting [I pointed out this symptom with (?!) as a bewilder one, while now I
know it as frequent symptom. Food intolerance does not occur. She is greeding
for sweet things, in particular ice creams. Meat or cube broth does not
interest her. She has always hunger, but her control on it is severe, because she
fears to grow fat. Nighttime muscular cramps do not happen, as well as drooling
during the sleep. By day she has to often urinate. She has fat hair, doesn't
suffer from any allergy, has usually constipation.
First diagnosis: Recurrent atypical depression.
Test therapy (daily doses, by the oral via):
Citalopram stopped. I prescribed: Pyritinol 50mg; Glutamine 62.5mg; Pyridoxine
150mg; Carbamazepine 200mg; Diazepam 5mg; Amitriptyline 10mg + perphenazine
2mg.
August 1999, the first checkup after 34 days
of drug therapy. She is going better, with fewer panic attacks. Now, she
doesn't have more crying episodes. Her head is less crowded of intrusive
thinking. The lump in the throat disappeared, she has few tremors, less
tachycardia, less fear of becoming crazy. She is always dissatisfied of
anything. Fear of fainting reduced. Her psychotherapy stopped.
Because of always poor control for bulimic
fits, so she tries to attenuate the swallowed excess by doing gym exercises in
her house. Now, she has less urge of urinating during the day. The emptying of
her bowel did not change. Hot flashes occurred. She has always feeling of
having her body cold. The frontal headache stopped, but neck tension persists.
Therapeutic variation (daily doses, by the
oral via): Glutamine 125mg; Carbamazepine 400mg.
October 2000, the second checkup. She did
enough well even if in the autumn 1999 and in spring 2000, following the
seasonal change. Since reappearing panic attacks, she had to increase the doses
of diazepam and of carbamazepine, every time for a month about. Her job is
going well. In the premenstrual phase she is irritable. Now, she doesn't have
more fear of becoming crazy.
The headache reduced very much, and it
appears no more than once every month, and it are less painful. She eats always
badly because greediness impulses come out. The frequency of urination amounts
to 3-4 episodes daily. Hot flashes stopped. Now she does not feel cooled
anymore. Her basic depressive condition is evident.
Therapeutic variation (daily doses, by the
oral via): Amitriptyline + perphenazine stopped. I prescribed haloperidol
0.8mg; Amitriptyline 16mg.
April 2001, the third checkup. She is doing
enough well, without heavy moments of panic attacks. Her diet is always badly
done, and she alternates attempts to refrain with bulimic excesses. For the
first time she says that she has tremors when she goes to hypoglycaemia [?!].
She is taking too much laxatives. She inclines much to sleep with drowsiness
during the day [we are in April!]. She practises tennis. The headache is quite
missing.
Now, she is less irritable in the
premenstrual period, less greedy than sweet things, and frequent need to
urinate does not occur anymore. As for her health, she had only a cold. There
is no lack of pleasure in her sexual relationships.
Current therapy (daily doses, by the oral
via): Glutamine 250mg; Carbamazepine 400mg; Pyridoxine 75mg; Haloperidol 0.8mg;
Amitriptyline 16mg; Diazepam 5mg.
October 2001, the fourth checkup. This time
she says she does not have more fear of becoming crazy [I hope!]. Panic attacks
were rare. Perhaps she bothers less her mother and her sister, with her true or
supposed problems. When she does not attend her job, she sleeps more. Now she
is engaged, with a sportsman, and she is very happy. She says that she is
crying because her happiness. During her working time her office head does not
give her much to do.
When she does nothing, negative thoughts
come out, and rare times about her engaged man. Sometime she sleeps less,
because she was late with her engage, who brought her at home of his parents in
another town of the same region. About her engage she is jealous, perhaps
without true reasons. Some time she wakes up during the night because has
hunger. In spite of everything, she is not doing badly.
Current therapy (daily doses, by the oral
via): Glutamine 250mg; Carbamazepine 400mg; Pyridoxine 75mg; Haloperidol 0.8mg;
Amitriptyline 16mg; Diazepam 5mg.
End April 2002, the fifth checkup. She is
doing fairly well, and her job does satisfy her. Since one month she has the
usual drowsiness in April. Now she is eating in a messy way and became
constipated. Her belly has blowing. A moment of mental derangement occurred, as
well as memory problems and some dysmorphophobic traits. She is afraid of lose
the relationship with the reality. In the past time she had only three panic
attacks, of minor intensity and short length. In the premenstrual period, she
has colic pain.
Therapeutic variation (daily doses, by the
oral via): Diazepam sopped. I prescribed: Glutamine 125mg;
S-adenosil-l-methionine 100mg; Bromazepam 1.5mg + propanteline bromide 15 mg
---> Bromazepam 1.5mg.
November 2002, the sixth checkup. No more
panic attacks happened. She is always messy in her diet. She is doing gym
exercises but she has the feeling of having few time. Now, she is irritable and
lately sleepy. Her waking up is at six o'clock in the morning for going in the
bathroom. Recently, she had joints ache of the shoulders, and has taken
anti-inflammatory drugs, which gave her stomachache, not being all over. About
her insecurity, she says that it is unchanged.
Some times she fears that misfortunes happen
to beloved persons. The Bromazepam + propanteline bromide induced her some
bother to the bladder with need to urinate frequently, but it reduced with the
only bromazepam. She becomes bad with the persons whom is fond of each other.
Therapeutic variation (daily doses, by the
oral via ): Glutamine 250mg; S-adenosil-l-methionine 200mg.
March 2003, the seventh checkup. She has
relapsed in February, then she confessed of having stopped the carbamazepine
since July 2002, by her initiative, because she was well off. Last November she
did not tell it. Two panic attacks occurred in premenstrual periods and even
during the last menses. Now, she is giving TENS for the cellulitis. Recently
she is much irritable and "rabid" in family. I asked to do an EEG
examination.
Therapeutic variation (daily doses, by the
oral via): Restarted carbamazepine 400mg.
May 2003, the eighth checkup. The EEG had
this report "Within the normal range," but I saw personally the
graphic, and I observed theta waves sequences mainly in right temporal areas.
For the age (> 25 years), these should not be considered as normal.
She sudden changes her mood, for no reason,
but not so intense as she had in past. For a short time, she did well. Now, she
is frightened, with slowed down movements, and confused conscience. She had
some non realistic ideas. Even alert feelings happened. She does as stuffed
with wadding. Sudden neurovegetative reactions occur.
She has moments of "kindness-like"
to which she does not recognize herself. When she doesn't do exercises, in the
evening she is more in tension, Compared with last March, she is lesser
irritable, but more abulic. She has still panic attacks, even if they seem less
frequent. Various phobias came out, however without stopping her. Her
self-esteem much diminished.
Therapeutic variation (daily doses, by the
oral via): Carbamazepine 500mg. Bromazepam 4.5mg; Nicotinamide 250mg.
October 2003, the ninth checkup. Altogether
she did well off until the October beginning but now she has primarily negative
days. At the beginning of August she started with 100mg/daily acetyl-salicylic
acid assumption (on a trial basis for a month) and was well off until nearly
the end of September. She had a little relapse that she attributes with not
easily believable reasons. If she spends more time in bed, she worsens.
Now she cries easy, she has apathy, and has
the feeling of cold into her body. A fine tremor can be observed in her left
body side. Bad thoughts and feelings against others occur. Till the period of
holiday in Sardinia, she has had sleepiness.
Therapeutic variation (daily doses, by the
oral via): Haloperidol 1.2mg; Acetyl-salicylic acid 100mg.
January 2004, the tenth checkup. She has
broken with the new engage, for futile ("stupid") reasons, in facts
by slandering and insulting his parents, without any justification. From early
December the bromazepam grew to 6mg dailY, because, after a period of comfort,
she started to become a little worse.
From half December she was aware of strange
thoughts, either aggressive and persecutory. Right after Christmas she had
sudden falls her mood, followed by asthenia and abulia. The diet is a little
more controlled, but with a lot of work. I asked a new EEG examination.
Prescribed therapy (daily doses, by the oral
via): Bromazepam 6.75mg; Carbamazepina 300mg; Etosximide 250mg; Amitriptyline
20mg; Pyridoxine 150mg; Hloperidol 0.6mg.
June 2004, the eleventh checkup. Even
this time the EEG, acted on last March, had the report of "within the
normal range," and no consideration was paid to the observable presence of
theta waves sequences with temporal prevalence, mainly in the right half-brain.
As compared with the previous one, the basic alpha waves ground is better
characterized.
She did not badly if not for some episodes
that alarmed her: a lump in the throat, in a premenstrual period, a sudden
agitation episode with desire to run away, that luckily lasted only few, and a
bulimic episode. Lately, always in the premenstrual period, while she was
eating an ice-cream, she had a strange impression, made of strongly negative
thoughts that have shaken it. She had an internal fear, for no reason and she
stopped for a certain time. She always takes too much laxatives.
Therapeutic variation (daily doses, by the
oral via): Clobazam 10mg.
February 2005, the twelfth checkup. She is
doing better, even if she has the habit of staying to much at home. Usually she
sleeps too much, about 11 hours and half. If her diet exaggerates, she tries to
consume the caloric excess by doing exercises.
Now, she became a little dysmorphophobic, or
perhaps it has always been no. Some times she has bewilder fears, and to times
it is seemed her to feel voices without any presence [acoustic
hallucinations?]. As for health, she did well off.
I asked a new EEG examination.
Prescribed therapy (daily doses, by the oral
via ): S-adenosil-l-methionine 200mg; Bromazepam 6mg; Carbamazepine 400mg;
Etosuxiimide 250mg; Amitriptyline 20mg; Pyridoxine 75mg; Haloperidol 0.6mg.
The EEG report (February 2005): The basic
layout is made up by alpha waves rhythm of 9-10hz medium-low voltage,
particularly evident in the occipital areas, reacting, asymmetrical with
prevalence to the left side, unstable in the centre-temporal derivations,
without any paroxysmal elements, but with spread presence of sharp waves, less
rare to right side. There are mingled bilaterally short theta waves' sequences
of 5-6 Hz, diffused in the centre-temporal derivations, and more frequent in
right temporal areas. The hyperpnea increases their frequency while the ILS
does not modify them.
Conclusions: The layout is within the
limits of the norm, with the deceleration presence and sharp waves, probable
signs of previous brain suffering, both sensitive to hyperpnea.
Discussion.
In this patient the epileptic depression is the
only compatible diagnosis with a complicated clinical history like that and
with the persistence of the EEG alterations. Of the individual features of the
five preceding cases ( not always all six seen) and here reported:
1. Here too a poor response to the
serototoninergic drugs, tricyclics and SSRIs;
2. The change of the mood is recurrent and
sudden, and it can be such long lasting, for weeks or months.
3. It is the same for the lack of a some
relationship with external causes clearly identifiable;
4. It is also the same for 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. Some positive variation of the
personality following this therapy, like in Cocchi 2004b, but they were
unstable.
The first five can be observed even here,
while for the sixth there would be a heavy interference with troubles of
half-brain dominance.
Since the first consultation I observed and
I reported symptoms that pointed out problems in this field. I could have
expected that to the test "Which is the opposite of the colour Red?"
her answer would have been Green ( The complementary of the Red ) or White (the
opposite of the Black) ( Cocchi, 2003) but, evidently, the depressive brain
situation was dominant. In the following checkups other symptoms of inverse
half-brain have been found, namely:
- She is always dissatisfied of anything
(August 1999);
- She says that she is crying because her
happiness. (October 2001);
- When she does nothing, negative thoughts
come out, and rare times about her engaged man. (October 2001);
- Some times she fears that misfortunes
happen to beloved persons. (November 2002);
- She sudden changes her mood, for no reason
...(May 2003);
- She has moments of
"kindness-like" to which she does not recognize herself. (May 2003);
- Bad thoughts and feelings against others
occur. (October 2003);
- She has broken with the new engage, for
futile ("stupid") reasons, in facts by slandering and insulting his
parents, without any justification. (January 2004);
- .... she had a strange impression, made of
strongly negative thoughts ... (June 2004 ).
Three EEG examinations excluded epilepsy, as
commonly understood, but in the first two, subsequently examined by me, there
were theta waves' sequences, mainly referable to temporal zones of the right
half-brain. They were even observed and reported, at the end, by who examined
of the third EEG. It corresponds to what pointed out by Matarazzo, 1976, in
cases of chronic depressions.
" ... a sudden agitation episode with
desire to run away ..." (June 2004) seems exactly the known symptom
temporal epilepsy.
On other hand "... some myoclonias and
muscular hypertone in the left body side." (May 2003) points on the right
half brain as mostly disturbed.
The stop taking of the carbamazepine
"since July 2002, by her initiative, because she was well off." Is a
fact known by the author on March 2003. It has been followed from a worsening
of the psychic conditions not fully returned, up to now, to the preceding
state. If we want it, it may be considered a countercheck of the epileptic
implication.
Conclusions.
This sixth reported case of recurrent
atypical depression in a young woman of 26 years at first examination and
followed for six years, has led to the definite diagnosis of "epileptic
depression", only suggested in the five preceding cases.
The EEG alterations, mainly in right
temporal areas, concern a brain area already known to associate convulsions
with motor and psychic symptoms. The fact that a partial epileptic form shows
exclusively (or nearly exclusively) psychic symptoms, doesn't then have to
amaze. Unless we doubt that the epilepsy may maintain an exclusive division
between mind and body.
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>.
Cocchi R. A fifth case of atypical
depression, recurrent, with the altered eeg (possible epileptic depression) in
a woman of 44 years at the first consultation. 2005
<www.stress-cocchi.net/Depression10.htm>.
Matarazzo EB. [Chronic depression and
temporal lobe dysrhythmia] : Arq Neuropsiquiatr. 1976, 34: 173-187. (In
Portoguese, quoted by Medline).
Posted on internet il 6 May 2005.
Copyright by Renato Cocchi, 2005.
Author's address: Dr Renato Cocchi, via Rabbeno, 3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions
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