A THIRD CASE OF ATYPICAL
DEPRESSION, WITH TINNITUS, IN A 38-YEARS-OLD WOMAN. ITS IMPROVEMENT WITH
ANTISTRESS DRUG THERAPY.
Renato COCCHI, a neurologist and medical
psychologist.
(Other two cases with atypical depression, stress and tinnitus)
Summary.
It is the report of a 38-years-old woman
case history, suffering from atypical depression since several months. In spite
of the current therapy with escitalopram and alprazolam, it did not show any
sign of improvement. There were also troubles of the half-brain dominance.
Recently she started to sense some tinnitus into both the ears, but more into
the left, as a water flowing type. A different therapy with antistress drugs
(glutamine, pyridoxine, carbamazepine and oxazepam) + chlomipramine, after 35
days, according to the patient, drew to poor or null results.
There was a clear improvement after 64
days from the starting of the therapy, while there was a nearly full resolution
after 152 days from the beginning of the therapy being doubled of the
carbamazepine dosing as well as the initial dosing of the chlomipramine. Even
the tinnitus is practically missed.
Key words: Depression, stress, intrusive
thinking, tinnitus, drug therapy, glutamine, pyridoxine, chlomipramine,
carbamazepine, oxazepam.
Drug modulation of stress reactions
It came to my observation an other case of
atypical depression lasting several months, in spite of the current
antidepressant-anxiolythic therapy, in a woman of 38 years. Recently some
both-sided tinnitus appeared too. Since the case has shown unusual features,
even for the tinnitus, I wrote here its history.
The case history.
The end of July 2004, the first
Consultation. A 38-years-old woman, with a strong affective not legalized
relationship, and a child. Her job is within the advertising.
Several months ago, she started with panic
attacks, which are going on, but she is now very depressed, discouraged, with
loss of any hope to recover.
Born postmature, with caesarian section, she
did not have pathological neonatal jaundice. She does not know about particular
symptoms or troubles in her first year of life. At school she did well in
Italian. Perhaps she was timid. She has been jealous of a cousin girl. She did
never suffer from headaches. As a child she was speaking much during her sleep,
and was even somnambulant. During her pregnancy she did well off.
Symptoms of the troubled half-brain
dominance: To the test "Say to
me the opposite of the colour Red?", she answered Blue. She uses to see
any thing negatively. Always she is undecided. Her head ha intrusive thinking.
Without any need she does not count objects.
Other depressive symptoms: In the morning she is particularly depressed and
she would never get up, to do not face the day. She is hungry of air and she
has tachycardia, does not show irritability, nor oversweating.She likes to eat
cheeses (a compensation for a larger introduction of triptophane). Sometimes
she had suicide ideas.
Stress symptoms: Now she has
tiredness, bears badly both the cool and the heat, is intolerant to the light,
to the noise and to the confusion. Her head is felt "heavy," stupid.
She has normal pleasure for the sweet things, but she refuses the meat or cube
broth. Her diet is balanced, with the vegetable and fruit intake, but her
appetite is poor. Her hair is fat. There is not drooling during her sleep, and
rarely she talks during it, does not have nighttime muscular cramps. She did
not reported colitis or diarrhea. In the premenstrual period she smokes much
more. She has disbandment and fainting feelings, and her sexual desire lowered.
Currently she takes escitalopramm,
alprazolam and flowers of Bach as therapy.
Temptative therapy (daily doses, by the oral
via): Eescitalopram and alprazolam stopped. I prescribed: Carbamazepine 100mg;
Oxazepam 7.5 mg; Chlomipramine 10mg; Glutamine 125mg; Pyridoxine 150mg.
Beginning September 2004, the first checkup
after 34 drug therapy days.
She affirms that she not had relevant
variations on her well-being or perhaps is feeling just a little better.
Moreover, she tells that now she does little head movements [shakes or tics? ].
Depressive symptoms: She feels now much agitated, much scary, and does
much labour to recover. She is a little better in the morning, but in the
afternoon she is still doing badly. Panic attacks were fewer and more
controlled: in all this period only one occurred. At the morning she succeeds
to get up better. Now she has less air hunger and perhaps less tachycardia.
Stress symptoms: She has more energy. Perhaps fewer feelings of
disbandment and of fainting occurred. The need of urinating frequently remains,
as first. The sexual desire improved. She doesn't bear the confusion, bears
more the noise, but the light gives her even a little pain. Her hair is fatter.
Symptoms of the troubled half-brain
dominance: Negative thoughts are not
the rule. Perhaps she is a little less undecided.
Tinnitus: Since one week she has a tinnitus as a waters
flowing type, in both the ears, but more into the left one. Her hearing is
normal.
Therapeutic variation (daily doses, by the
oral via ): Chlomipramine 20mg; Carbamazepine 200mg.
Beginning October 2004, by email from the
patient, after 64 days of drug therapy days:
Positive notes:
- Since 10/15 days I have a general improvement;
- I succeed with always less difficulty
in frequenting crowded places;
- I decreased the fear of the noise and
the bother of the light;
- I have less heaviness in my head;
- I have more energy to do the things;
- My look is not anymore as beside an
aquarium;
- My appetite has normalized;
Negative notes:
- The problem of the tinnitus is
diminished but there is still;
- I sleep always much in comparison with
my normalcy;
- I am afraid of the heights (with a
little drive of throwing me down);
- Since began this depression I have a
pain in the index and medium fingers of the right hand (Is it an arthritis?)
- I have attacks of prolonged
constipation;
- I don't still reach the trust in myself
and consequently I am not still returned to the responsibilities of my life;
- I am fighting a little more with the
sadness.
By email, in the middle of November.
New notes:
- The tinnitus improved still,
practically it continues to decrease in intensity.
- I am sleepy always much as for with my
normalcy, and now I am persecuting by yawns during all day.
- About the fear of the height I do not
know how tell you.
- The fingers' pain of my hand completely
disappeared.
- As I wrote you, now I am suffering from
some headache and of prolonged constipation (4/5 days or more ).
- I did not still recover any trust in
myself and consequently I did not yet return to the usual responsibilities of
my life.
Mainly I do not feel me as creative and I
do not have ideas on how to use my time.
My willing to react is increasing but it
is not still enough.
- I am sensitive, but not sad.
Therapeutic variation (daily doses, by the
oral via): Chlomipramine, 10mg.
The first decade of December 2004, the
second checkup after 126 days of drug therapy. She is better and recovered her
strength, but she did not resume her job, because she has fear to not succeed.
She has neither recovered the calm to go to accompany her son at school and to
take him back it. Sudden tachycardia fits come out. She goes on to yawn, but
less.
Now, she is sleeping well. Much constipation
occurs. A foot's dermatitis to the plants appeared since a month. Oversweating
is always exaggerated [?]. Still myoclonies to the head ( starts or tics), but
they seem going down. The feelings of disbandment are perhaps less intense and
her head ha less intrusive thinking.
When compared to the initial state, the
tinnitus is 80% diminished (according to her subjective evaluation). Always
worried if she needs to stay alone, but less than previously. In some days she
has always evident eye sockets. She does better her housework because she is
"more conscious" [lwith more willingness?].
Therapeutic variation (daily doses, by the
oral via): Chlomipramine stopped. I prescribed Amitriptyline + Perphenazine
10mg + 2mg; Carbamazepine 300mg; Bromazepam 1mg.
First ten days of January 2005, by email after 152
days of drug therapy:
.... . you led me the possibility of
enjoing a beautiful Christmas.
Since my last consultation I had a strong
improvement. I have nearly again the full control of my life.
As usual I shall give the list of my
symptoms, as it follows:
- The tinnitus improved anymore, and now
it is practically missed;
- I am not sleepy like some months ago;
- The fear of the heights disappeared;
- I do not feel anymore the pain of my
hand fingers;
- Now I do not suffer more from the
headache and of constipation;
- I got again the trust in myself and
consequently I came back to the responsibilities of my life or nearly it;
- I am still emotional but not more sad;
- My feet's dermatitis did not disappear:
- I have microscopic fits as beginning of
fear ( like little dizziness ). So, when I speak with somebody without paying
him any attention and when I am outdoor alone with my child but I succeed to
win them by giving not them much importance.
This seems a good beginning of the new
year.
Beginning March 2005, the third checkup
after seven months of drug therapy. She is doing very well. Now she is "much
more real with herself and with the others." Since a month resumed her
job, going by feet there without any difficulty. Still she does not use her
car, by fear of a panic attack, while driving. Some air hunger episodes
occurred. The tachycardia is more reduced. She has recovered to go to take her
child at school. Now, she is yawning much less. Constipation rarely occurs.
Oversweating decreased, and myoclonias missed. The feeling of unsteadiness is
much diminishes, and her head is more free of intrusive thinking. Currently she
is scoring 2% her tinnitus. Now, she bears more to stay alone. Days of pallor
and eye sockets reduced. The premenstrual syndrome is diminished and it is more
manageable. Headaches disappeared. She has always a strong desire to smoke.
The current drug therapy does not vary.
Discussion.
In addition to the core symptoms of
depression, atypical depression is defined by the ability to feel better
temporarily in response to a positive life event, plus any two of the following
criteria: excessive sleep, overeating, a feeling of heaviness in the limbs and
a sensitivity to rejectionin the interpersonal relationships.
The diagnosis of the depressive form of this
case, following the DSM-IV, 1994, could be Major Depression, Single Episode
(F32.2). The fact however that the depression maintains in spite of therapy
with escitalopram confirms its atypical feature, which, of the rest,
corresponds to specific criteria for which. So, to the diagnosis, we may add
"with Atypical Features".
Although termed as atypical, this type of
depression is currently the more common subtype, according to Nierenberg and
coll., 1998.
Like any other atypical depression it would
have a better response to IMAOs as compared with tricyclic antidepressants, and
better to tricyclics than to SSRIs (Nelson and McElroy, 2003). The escitalopram
taken by this patient is just an SSRI drug.
It may be of interest to observe that the
depression improved after replacing the SSRI drug with a tricyclic, (the
chlomipramine), and adding antistress drugs (carbamazepine, pyridoxine,
oxazepam for the alprazolam, glutamine). The favourable response was not quick,
and I had to increase the doses of the chlomipramine and the carbamazepine.
The troubles of the half-brain dominance
were a little improved (Not always negative thoughts. Perhaps the patient was a
little less undecided ).
It deserves some attention the result on
tinnitus, which appeared only recently. She affirms that that "is
diminished but there is still." Probably the patient doesn't know the
usual prognosis of the tinnitus, which is considered resistant to any drug
therapy. Even in the preceding case of recurrent depression, perhaps atypical,
with tinnitus (Cocchi, 2004), the tinnitus diminished, but after nearly double
period of therapy.
To point on that, in both cases the tinnitus
arose on a depressive base, and the relationships among depression, stress and
tinnitus is the object of much interest.
This report points out a particular aspect
of the physician-patient relationship.
During the first checkup her resuming
admission of not having had" relevant variations on her well-being"
did not correspond to what then sprung from the interview, with an exact
checkup of all symptoms and behaviour. All the sentences that start with
"perhaps", in fact related to positive data, but the patient seemed
not inclined to accept them.
To avoid fighting her uselessly, I offered
her the compromise to transcribe these answers in a doubting way. My personal
impression was that her negativist attitude, from a trouble of the half-brain
dominance, influenced even on the self-evaluation and consequently on the
answers she gave me as her physician.
The physician, if he does not collect and
does not punctually check the symptoms, may be misled and quite forced to wrong
drug prescriptions as for quantity and quality. This behaviour persisted also
in December 2004.
In March 2005 the situation was in away of
full resolution. Even the tinnitus nearly missed.
Moreover, even the premenstrual syndrome
attenuated (Cocchi, 2003 ).
Conclusions.
A woman of 38 years suffering of atypical
depression since several months, in spite of the current therapy with
escitalopram and alprazolam, she did not get any relief. Lately she started to
sense some both ears sided tinnitus.
The antistress drugs prescribed (pyridoxine,
carbamazepine, and glutamine ) and the substitution of the escitalopram with
chlomipramine, and of the alprazolam with oxazepam, after 152 days it led to
disappearance of the depression, to a reduction of the troubles of the
half-brain dominance and to nearly disappearance of the tinnitus, as it
happened in the previous patient (Cocchi, 2004).
This last datum, if subsequently confirmed,
could bring to new ideas on the origin of the tinnitus, and on its treatment.
(Other two cases with atypical depression, stress and tinnitus)
References.
American Psychiatric Association. Diagnostic
and statistical manual of mental disorders (4th ed). Washington DC: American
Psychiatric Association, 2000.
Cocchi R. The case history of a 32-years-old
woman with premenstrual syndrome by now rebellious to usual therapies, improved with
antistress drugs. January 2003 <www.stress-cocchi.net/premest1.htm>
Cocchi
R. Long lasting recurrent (atypical?) depression with tinnitus in a
37-years-old man. Its improvement with antistress drug therapy. October 2004
<www.stress-cocchi.net/Depression3.htm>
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.
Posted on Internet
on 8 October 2004. Copyright by Renato Cocchi, 2004.
Author's
address: dr Renato COCCHI, via Rabbeno, 3
42100
Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions