AN ATYPICAL DEPRESSION
WITH AN ALTERED EEG (EPILEPTIC DEPRESSION?) AND HIS EVIDENT IMPROVEMENT WITH
ANTIEPILEPTIC AND ANTISTRESS DRUG THERAPY.
Renato Cocchi, a neurologist and a medical
psychologist.
(Five other similar case histories)
Summary.
An adult, aged 32 years, had a current
atypical depression, without any response to amitriptyline and etizolam. With a
more complex therapy, where carbamazepine, glutamine and pyridoxine have been
added after a good initial improvement, a sudden relapse occurred for no
evident reason. An EEG examination showed theta waves in parietal-temporal area
mingled to a basic alpha rhythm inclined to slow (8-9 Hz). An increase in the
dosing of the carbamazepine and of the etizolam led to nearly total
disappearance of the depressive symptoms since nearly nine months.
It is possible that exists a partial
epilepsy whose only symptoms are of psychic type as ictal depression.
Key words: Atypical depression, stress,
epilepsy, EEG, theta waves, epileptic depression, perinatal trouble, drug
therapy, etizolam, carbamazepine, pyridoxine.
Drug modulation of stress reactions
I
had the chance of observing a curious and unusual form of depression that I
would say as atypical even if it doesn't fully correspond to the DSM-IV
criteria for this diagnosis.
The
altered EEG, while without an epileptic form layout, at least as intended usually
for such, has induced the suspect that the trouble of the brain rhythm was the
starting point for the change of the mood. Thirteen months after the beginning
of the drug therapy I decided to report it.
The
case.
Third
first of October 2003. Male, of nearly 32 years at first consultation, with a
scientific degree, engaged.
He
affirms of being depressed since four months, for problems linked to his job
that does not satisfy him. For the same reason, he recently resigned from an
other firm.
Prodromes:
He is born from a complicated delivery. In the first year of his life he did
not sleep, was pale and had easiness to upper respiratory tract infections. Now
he says that he was a little solitary child, or with fewer friends. At school
he did better in mathematics.
Depression: Usually
he is better in the afternoon. Now, he is easily crying. If he is badly, he
inclines to do it known, but he does not look for the company. Panic attacks
occur. He is well falling asleep, but he does not remember his dreams. If the
sleep interrupts, he doesn't succeed to resume it. He doesn't have difficulties
in the weekend, for which he was not forced to invent activities that hold him
busy. Sometimes he has tachycardia for no reason, but he has not air hunger.
Mediastinal oppression occurs, with the lump in the throat. Currently he is
taking drug therapy with amitriptyline + perphenazine and etizolam.
Possible
problems of altered half-brain dominance: He always had difficulty to take
of decisions. He inclines to see the reality as negative. To the test
"Which is the opposite of the colour Red?" he answers, with some
indecision, Black. Perhaps He has sudden and extraneous negative feelings
against beloved persons. It seems he has trouble to admit it. His head is always
full of thoughts that disturb his attention and concentration. Some times his
head has continuously repetitive musical tunes. In some moments he realizes he
is counting serial objects, without any need to do it (EG. Steps of a
staircase, tiles of a floor, etc.).
Stress
symptoms: He is potentially pale, but he is indifferent to warm and
cold. Sometimes oversweating occurs. Sometimes he has colic and diarrhea.
During the day he needs often to urinate. He denies nighttime muscular cramps.
When he wakes up, he is tired. Usually he wakes with his penis erection. In the
morning he doesn't have hunger at once. Dyslalias do not happen. Rarely he has
disbandment feelings, but no feelings of faint. His hair is neither fat nor
dry. He bears badly the noise, but perhaps not confusion. He has some episodes
of the right temporal headache, and has burning feelings in his eyes. Usually
he eats more sweet foods than the normal, in particular more chocolate. He has
a normal preference for the meat or cube broth.
Test
therapy (daily doses, by the oral via): Glutamine 250mg; Pyridoxine 150mg;
Carbamazepine 100mg; Amitriptyline + perphenazine 25mg + 2mg; Etizolam 1mg.
Second
third of November 2003. The first checkup after 37 days of drug therapy. He is
better and bears more his job. Panic attacks were scarce. He mentally feels
clearer, and less undecided, with his head less full of thoughts. The need to
count uselessly serial objects reduced.
Currently
he is eating less chocolate. Still oversweating occurs, as first. Colic and
diarrhea did not happen. Now he is sleeping well and he wakes up less tired. He
is doing well both in the morning and in the afternoon. He has more gladly
breakfast early in the morning. He does not know if he were less pale.
Mediastinal oppression and the lump in the throat decreased. Weeping for no
reason went much down. It is growing his facility to be with other persons. The
tachycardia diminished.
The
need of urinating frequently, is still present. He always bears poorly to the
noise, but less than previously. He did not suffer from the headache anymore,
and the burning of his eyes reduced. Problems in the sexual activity did not
appear.
Therapeutic
variation (daily doses, by the oral via): Etizolam 1.5mg.
Beginning
of the second third of the January 2004, the second checkup asked in advance by
the patient. For no evident reason a depressive crisis reappeared. He sees all
black again, his work inclusive. Now he has fear that he cannot ever recover
again. No tachycardia occurs and the need to urinate often came back. His eyes
are burning when he is crying. His headache did not reappear. I asked an EEG
control.
Therapeutic
variation (daily doses, by the oral via): Carbamazepine 200mg; Etizolam 2.5mg
(to start after the EEG control).
EEG:
The basic alpha rhythm counts 8-9 Hz, of medium intensity, asymmetrical, and
interposed by theta rhythm, with right prevalence in the parietal-temporal
area. It was considered as normal by the neurologist who did the report of it.
First
third of May 2004, the third checkup. Now he is well. On March he had still
some mood negative variation, but since April he had a stable mood. The work is
not going badly, and he is accepting it. He doesn't have interpersonal
problems. The tachycardia disappeared again and the need to urinate often
reduced as well. The right temporal headache becomes a much rare fact. His
weeping stopped.
The
appetite is normal, without sweet things and chocolate abuse. His face is more
coloured. The repetitive musical tunes in his head did not go further.
His
head is not more full by thoughts. He needs less counting objects, without any
reason. He wakes up tired only he went to bed late. His sexual activity did not
have any alteration.
Therapeutic
variation (daily doses, by the oral via): Amitriptyline + perphenazine 10mg +
2mg.
End
November 2004: The fourth checkup, after 13 months of drug therapy, and nine
months of recover of his depression.
On
June he married. His psychophysical state is running very good. In this time he
waited the usual autumnal relapse, which however it did not come, in spite of
the seasonal variation that probably intense, as much resentful from other
patients. His job started to like him and to give him many satisfactions.
The
relationship with his own "territory" much improved. Even many other
persons find him as different, and improved. Among them, his previous
executive, much favourably astonished. Attention and concentration are
improved. It happens rarely to count objects for any reason. The need to
urinate often comes back only in the days where he is a little in tension.
Oversweating is now much less.
He
asks to put down the drug regimen and I satisfied him, and I advised him upon
the risks of such a decision.
Therapeutic
variation (daily doses, by the oral via): Glutamine 125mg; pyridoxine 75mg;
Carbamazepine 200mg; Etizolam 0.5mg in the morning; Amitriptyline +
perphenazine 10mg + 2mg, only five days every week.
Discussion.
I
wanted to report this case because it exemplifies something that is not new in
my clinical experience. Even in other subjects with surely atypical depression
and with ictal coming out, to my request for an EEG control I had normalcy
responses even in presence of anomalies of the EEG graphic.
It
is well true that nearly always the graphic was not of an epileptiform type,
but the usual report of normalcy is dichotomous in a superficial way. Or one
patient is an epileptic person (like as we know the epilepsy) or he is not.
That is to say: Or we are in Rome or we are in Milan. But between Rome and
Milan there are a lot of things that should not be ignored, and should be
appraised according to their possible relationship with the clinical state. The
ictal aspect has at once lead to some suspicion.
A
hyperosmia and a ictal headache following a heavy olfactory stimulus are
answering well to an antiepileptic and antistress drug therapy (Cocchi, 2004).
On
another part, short-lasting sudden episodes of green colouration of the whole
field of the vision, which persist six months after a cranial trauma (Cocchi,
2004) can have an explanation only in terms of "epileptic
equivalent", if we may use an old specification.
For
what concerns the depression, or we accept as true that it has no biological
bases - but antidepressant drugs show the opposite - or related specific brain
areas, as such, can go even by themselves to bioelectrical instability. So they
can drive to depression, without any apparent reason.
In
other words, and excuse me for my coarse definition, epileptic depressions can
occur, which have as the only epileptic symptom, the sudden variation (a fit)
of the mood. They will be therefore a form of partial epilepsy.
I
suspect that the use of the antiepileptic drugs in psychiatry as so-called
neuromodulators, - for the valproate, previously dipropylacetic acid, I began
to do over 25 years ago -, in fact it is exactly a true antiepileptic therapy.
The
present case has peculiar features. The patient had delivery suffering and he
confirmed it with specific troubles in the first year of life. There were
enough two symptoms out of, but he showed at least three of them. He had the
so-called introvert character, with social difficulty, while he had a type of
inhibiting depression (Cocchi, 1986). When he had the first consultation with
me, he reported a whole series of symptoms suggesting troubles of the half
brain dominance. He inclined to pessimism and to see the job situations as
negative. They were some signals of a basic depression, which drew him to
change his job and to be dissatisfied even of the current job.
Somehow
the body, with some difficulty too, could face it till the beginning of the
fourth decade of life, but then he could not sustain a discreet balance. An
evident depression came out, not answering to a tricyclic antidepressant and to
a benzodiazepine.
By
adding to the regimen even antistress and antiepileptic drugs, after a
short-term improvement the patient relapsed inexplicably, which pushed to the
request for the EEG control.
The
theta wave presence, which should not be found any more after 25 years of life,
led to hypothesize a link between his depression and the EEG troubles, nearly
surely as a residue of the perinatal suffering.
Redefined
the drugs dosing, four of which out of five are even of the antiepileptic drugs
(glutamine, pyridoxine, carbamazepine, etizolam) since from nine months he has
a balanced mood. Moreover, he is modifying positively his relationship with his
job and with the environment where he always lived and lives.
On
other hand these drugs are even antistress drugs and I need to remember that
the stress is the triggering of the epileptic fits.
If
then we want to say that this patient is changing his character, we could to
say it too, but this is a superficial affirmation. Nearly surely he is removing
a share of somatic depression that he has dragged since his birth.
A
final problem remains. If this form is, as it seems, a depressive epilepsy, why
it does not spontaneously disappear after the fit as all the other epileptic
forms do, excluding, perhaps, the continuous epileptic fits? Now this question
has no answer although there were described long lasting depressive epilepsies.
with an episodic or permanent depression, as epilepsies with temporal lobe
localisation. (Matarazzo, 1976).
(Two
other similar case histories)
References.
Cocchi R. Le depressioni infantili. In. Cocchi
R. Strutture e dinamiche
psicopatologiche in età evolutiva. Montefeltro, Urbino 1985: 163-183.
Cocchi R. Hyperosmia, and headache's fits from heavy, olfactory stimuli in a 35-years-old man of 35 years. An approach with antiepilectic and antistress drugs. 2004 <www.stress-cocchi.net/Other14.htm>
Cocchi R. Short-lasting sudden episodes of green colouration of the whole visual field, even persistent six months after a cranial trauma. 2004 <www.reversebrain.net/Case10.htm>
Cocchi R, Mastruzzo A, Ciccone A,
Osvaldi ML. L-glutamine et acide dipropylacetique comme psychotropes
subsidiaires dans le traitement des patients psychiatriques hospitalisés.
L'effect sur la consommation des neuroleptiques. Encephale. 1977, 3:121-32.
Matarazzo EB:
[Chronic depression and temporal lobe dysrhythmia] : Arq Neuropsiquiatr. 1976,
34: 173-187. (In Portuguese, resumed by Medline).
Posted on Internet on 6 December 2004,
Copyright by Renato Cocchi, 2004.
Author's address: dr. Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia
email: renatococchi@aliceposta.it
Drug modulation of stress reactions