A THIRD CASE OF RECURRENT ATYPICAL
DEPRESSION WITH ALTERED EEG (A PROBABLE EPILEPTIC DEPRESSION) IN A WOMAN OF 22
YEARS AT THE FIRST CONSULTATION.
Renato COCCHI, a neurologist and a medical
psychologist.
Summary.
A woman of 22 years at the first
consultation who had meningitis when she was 5, did report episodes of
recurrent atypical depression, which were coming at once, without clearly
identifiable causes. She was prescribed antidepressant and antistress drug
therapy, with clear improvement and increased intervals among relapses.
An EEG examination after four years
revealed not specific anomalies primarily to left half-brain. An EEG check
after 11 years from the first one and 15 years from the beginning of the drug
therapy, the EEG situation improved but not at all, with "irritative"
sharp-waves limited to the left temporal region. The case leads to think to a
like epileptic phenomenon with pure psychic expression (a probable epileptic
depression).
Key words: Atypical depression, stress,
epilepsy, EEG, theta waves, epileptic depression, meningitis, drug therapy,
amitriptyline, carbamazepine, benzodiazepine.
Drug modulation of stress reactions.
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I lately published two cases of recurrent
atypical depression as possible epileptic depression (Cocchi, 2004; Cocchi,
2004).
Meanwhile a woman with a somehow similar recurrent
atypical depression, followed by me since 1990, came to the checkup. In 1994
she underwent an EEG examination, the report of which revealed a type of
"irritative" alterations.
Then I did not think it as a direct link
with her depression. As this case is interesting, its report here below becomes
the third of what probably will be a little series.
The case history.
June 1990: A female, of 22 years at the
first examination, engaged. She dropped out the university after two
examinations, for poor concentration and presence of intrusive thinking, two
symptoms she still has. She does not smoke, doesn't drink coffee, doesn't like
alcoholic drinks.
Risk factors at the birth time are not
referred. She denies also the whooping cough, but she had meningitis in her
fifth year. When she was 14, she started to feel badly. Premenstrual syndrome
does not occur, but sometimes she has a short menstrual cycle. Usually, she
inclined to constipation.
There are no signs of either central or
peripheral neurologic dysfunction.
Symptoms of depression: Since a long time
she is depressed, with crying, and for it she had therapy with
s-adenosil-l-methionine. There are not other depressed persons in her family
now and in past. She is late leaving her bed, tired and badly, but doesn't have
morning nausea nor vomit. Now she is badly even in the afternoon. She has a
headache that locates badly, but probably it is starting from the frontal
areas. She is abulic and poorly affective, but without any anxiety.
She has irritability moments; However, she
does not express them. Usually, she has eye sockets. In past, she had air
hunger and a lump in the throat but no mediastinal oppression, nor stomach
ache. She does not like to be fatten up.
Noise and confusion bother her. Sometimes her
hands show some tremor. Tachycardia often occurs.
Stress symptoms: She is eating rather
continuously and is searching nearly always sweet foods, among which very much
chocolate. Meat broth is not a pleasure for her. Her hair is fat and her skin
is also fatty, not dry. The cold bothers her. She sleeps a lot and has
mandibular pain because she has nighttime and daily bruxism. Sometimes she
speaks during her sleep where she is drooling.
Nighttime muscular cramps do not occur. She
does not remember her dreams and does no bad dreams. Soon after the awakening,
she does not stretch. She never suffered from some stiff neck. Sometimes she is
affected by dyslalia. Her speaking slowed. Some asthenia moments occur. Now,
she needs to urinate often during the day. No oversweating reported. No faint
feelings, but unsteadiness, which already happened in past.
Other: In the junior and high school she did
better in Italian but she had a learning rhythm a little slowed down. Usually
she is better in summer. Her sight did not change. Her motility is now slowed.
She has some traits of derealisation.
Starting therapy (daily doses, and by the
oral via): Glutamine 125mg; Pyridoxine 150mg; Nimodipine 60 mg; Nortriptyline
10mg; Oxazepam 7.5mg.
October 1990, the first checkup after 111
days of drugs therapy.
Now, she is doing better, does not cry
anymore, her face is more beautiful. Intrusive thinking decreased. She sleeps
better, and she wakes up normally in the morning. Her diet is now more
balanced. Her headache disappeared. The hair did not lose their fatty feature.
She is always sensitive to cold. Drooling during her sleep decreased. Now she
has less mandibular pain, because the bruxism reduced.
She bears more noise and confusion. There
are even some days with eye sockets. Less tachycardia and fewer feelings of
unsteadiness occur. She is well all the day long and she became a little
overactive. Her hands show even some tremor. Now she has fewer dyslalias, less
asthenia and less irritability. Some days she needs to go often to void her
bladder.
Therapeutic variation (daily doses, by the
oral via): Oxazepam 22.5mg.
January 1991, the second checkup after seven
months of drug therapy.
Now, she is doing well and is more calm. She
found a new job that she likes much. Even the relationship with her relatives
improved. She sleeps well, her appetite is quite normal and her weight reduced,
which pleased her. The menses' cycle is regular as well as her bowel function.
She wakes up not tired. Her hair became stronger.
The tachycardia, the feelings of
unsteadiness, the headache disappeared. The dyslalias are missing. Now, she had
reduced the need to go to the bathroom to urinate. Perhaps she is less
sensitive to the cold. She has still some days with eye sockets.
Therapeutic variation (daily doses, by the
oral via): Glutamine 250mg; Oxazepam 30mg.
End April 1991, the third checkup. A relapse
happened after 10 months although she was taking her drug therapy. Now she is
badly, and she says that her "life is escaping from her hands".
Everything is indifferent, even pain and desperation. What the others are doing
is without any meaning for her. Her sleep is badly, with difficulty in falling
asleep, and early morning awakening (on about six in the morning) for her
habits.
She lost her appetite and subsequently
reduced her weight. The constipation returned. From time to time she cries and
the hands' tremor came out again. She is having intrusive and ambivalent
thoughts, with ideas of death, more exhibited than true. The intolerance to
noise reappeared. She feels without any strength, tired, and slowed down in her
movements.
The new regimen (daily doses, by the oral
via): Nimodipine, Oxazepam, Nortriptilina and Glutamine stopped. I prescribed
Pyritinol 100mg; Thiamine 125mg + Pyridoxine 125mg + cyanocobalamin 0.5mg;
Carbamazepine 200mg; Bromazepam 1mg; Haloperidol 1mg; Chlomipramine 25mg.
March 1992, the fourth checkup. Last autumn
she had a period of asthenia, treated for one month with glycine 150mg and
creatine 2g (daily doses, by the oral via), and it got over. Always engaged
with the same man, a little entrepreneur, she seems as dissatisfied of this
relationship. In her job, where it is the chief for the foreign countries
relationships, she runs well. Her sleep is regular. She did not grow thin again,
on the contrary she returned to her normal weigh. Now, she bears the noise as
usual, nor has the tremor in her hands. Her language is much more fluent. Since
a week she feels some tiredness, a fact that worried her. She doesn't cry and
has less intrusive thinking.
Temporary therapeutic variation (daily
doses, by the oral via): Carbamazepine 300mg; Bromazepam 2mg. The increasing
dosage of this two drugs should last two months, then it has return to the
preceding doses.
End July 1993, the fifth checkup. Now she is
well off. Her job runs very well, and she gains many acknowledgements, and the
workplace pleased her. She says that she did not still find an internal
balance. Currently she is without her engaged man, but the choice of a new
companion is hard to please because she now is very demanding, even in
relationship to her working role. The headache fully missed. Her appetite is
normal and her bowel function too. Now she sleeps well, but perhaps a little
too much. She did not cry groundless, and her head is no more blocked by
intrusive thinking, without ideas of death. The language is very fluent. She is
feeling a little tired.
Current therapy (daily doses, by the oral
via): Carbamazepine 400mg; Thiamine 62.5 [mg] + Pyridoxine 62.5 [mg] +
Cyanocobalamin 0.25mg; Haloperidol 0.5mg; Bromazepam 1.5mg; Fluoxetine 20mg;
Amitriptyline 20mg.
End April 1994, the sixth checkup. She tells
that she has had ups and downs, but she always overcame them. Now she is under
psychotherapy and she feels stronger. Her appetite is normal, but she inclines
to sleep much and leaves her bed a few gladly. Intrusive thinking came back,
and her work also is showing traces of it, as for her. Any of her work
colleagues seem however to be aware of it. I asked an EEG examination.
Therapeutic variation (daily doses, by the
oral via): Bromazepam 2.25mg for two months, then return to 1.5mg.
The EEG performed on 09 May 1994.
The report: 10-11 Hz alpha activity,
bilateral and symmetrical, with arrest reaction. There is an irregular
appearance of sharp waves, even of the band theta, as picked in sequences, and
with prevailing diffused expression, sometimes more evident on the left
half-brain. No variations follow the ILS.
The HP enhances those sharp waves.
In conclusion, good basic activity,
mingled with slow irregularities with bilateral "irritative"
features, enhanced by the hyperpnea.
End September 1996. The seventh checkup. In
last two years she did not badly, even if sometimes, for some months she had to
increase the daily dosing of Bromazepam. Now she is well off, but is a little
without appetite and has some problems of memory for the names. Of her
initiative she stopped the drugs of the morning. For which since months she is
taking only (daily doses, by the oral via): Carbamazepine 200mg; Amitriptyline
10mg; Haloperidol 0.5mg; Bromazepam 1.5mg.
Therapeutic variation (daily doses, by the
oral via): Choline alfoscerate 400mg for six months.
End September 1996. The seventh checkup. In
last two years she did not badly, even if sometimes, for some months she had to
increase the daily dosing of bromazepam. Now she is well off, but is a little
without appetite and has some problems of memory for the names. Of her
initiative she stopped the drugs of the morning. For which since months she i
taking only (daily doses, by the oral via): Carbamazepine 200mg; Amitriptiline
10mg; Haloperidol 0.5 mg; Bromazepam 1.5 mg.
Therapeutic variation (daily doses, by the
oral via): Choline alfoscerate 400mg for six months.
January 1997, the eighth checkup. As usual,
sometimes she had to increase the Bromazepam for dysphoric periods. This time,
such a strategy did not reach the good result. She has now an energy fall, and
is feeling herself as soft. Even some fear appeared. The reduction of the
strength came after the last menses and the cycle lengthened. Her sleep is
regular. Much hunger came out in the last days. She thinks that her asthenia is
contemporarily physical and psychic.
I prescribed injective therapy of
diencephalic phospholipids 500mg every alternate day and
s-adenosil-l-methionine 500mg, every second day, for a month. Therapy
variations (daily doses, by the oral via): Glutamine 250mg; Amitriptyline 25mg.
April 2001, the ninth checkup. She has
passed discreetly the last four years, from time to time adjusting the dosing
of the Bromazepam or doing again the injective therapy at least once in the
year. Currently she has a little relapse, for which she is feeling abulic and a
little dysphoric. Now, she has difficulty to maintain her work rhythm, which in
effects is high. Often she doesn't succeed to maintain her concentration and
she has drowsiness. She is always more dissatisfied of her engaged man because
now she doesn't think him more suitable to her personality development.
Constipation came out again. She feels her belly swollen and tight. The
menstrual cycle is again lengthened.
Prescribed therapy (daily doses, by the oral
via): Pyridoxine 75mg; Glutamine 250mg; Haloperidol 1mg; Delorazepam 0.5mg;
Carbamazepine 400mg; Amitriptyline + perphenazine 10mg + 2mg; Soluble
fluoxetine 30mg.
January 2005, the tenth checkup. In the past
time she ran quite well. In the February of the last year she definitely left
the old engaged man and she tried "serious" affective histories with
other men, but without any success. This depressed her of a little but she
forces herself "to learn to live alone". Now she is a little asthenic
and sleepy, but not in worrisome way. Meanwhile, I requested a new EEG.
31 January 2005, the EEG checkup.
The report: 10 Hz/sec basic alpha rhythm,
bilateral, symmetrical with the arrest reaction. Rare and isolated sharp waves
in the left temporal region, during the hyperpnea. No anomaly found at rest and
during intermittent light stimulation.
Conclusion: Rare aspecific
"irritative" aspects during the hyperpnea without specific
epileptiform anomalies and without suffering signs from a focus.
Discussion.
In this case history it is interesting the
fact that this person interrupted the university because the poor concentration
and the intrusive thinking. At her first examination, while I annotated these
two symptoms and their consequence, I had clear the relationship among of them,
it will happen years later (Cocchi, 1994).
The EEG examination, first performed in
1994, and checked again in 2005, showed marks of "irritability",
probably as the following to the meningitis of which she had when she was five.
The drug therapy with carbamazepine, lasting
for nearly 15 years, seems to improved the EEG with the disappearance of the
theta sequences, as in the second EEG not controlled by myself. The marks of
"irritability" are now only elicited by the hyperpnea.
Nevertheless, from time to time she has
sudden falls of the mood, usually moderate, and not always following
specifically induced events. These depressive mood variation could have been
faced with some therapeutic variation mainly of the banzodiazepine. More rare
were asthenic relapses with drowsiness, and trais of derealisation.
Even in this woman we can observe the
features of:
"2. Recurrent fit changes of the mood
that may be such for a long time;
3. Lack of any relationship with external
clearly identifiable causes;
4. An altered EEG but not meaningful for
epilepsy;
5. A good response to the antiepileptic and
antistress drugs;
6. Positive personality variations following
the therapy (Cocchi, 2004)".
I cannot speak of "1. Poor response to
the serototoninergic drugs, tricyclics and SSRIs;" because I never
prescribed such drugs alone, or with a benzodiazepine, but always in
combination with other antistress drugs.
I am always more convinced about the
existence of atypical depression that their base in a fit trouble of the EEG
rhythm, as a sign of a brain suffering in the past. In all three reported
cases, a temporal brain area is involved, but not necessarily the right one.
The trouble expresses as a recurrent atypical depression.
References.
Cocchi R. Problems of attention and
concentration leading to interruption of studying by high school and University
students: A report of 4 cases. It. J.
Intellect. Impair. 1994, 7: 29-38. <www.stress-cocchi.net/Droping1.htm>
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>.
Posted on internet on 9 February 2005.
Copyright by Renato Cocchi, 2004.
Author's address: Dr Renato
COCCHI, via Rabbeno, 3
42100 Reggio Emilia