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.
Renato COCCHI; a neurologist and a medical
psychologist.
Summary.
A woman of 36 years at the first
consultation in 1998, born after a very prolonged delivery, had recurrent
episodes of atypical depression, at times with prosecutory traits or
derealisation phenomena.
An EEG examination after three years
revealed both-sided aspecific anomalies (theta sequences and beta rhythm)
mainly in the right side, which involved frontal, temporal and occipital brain
areas. Six years after the beginning of the drug therapy, now mainly of the
antidepressant and antistress type, this woman goes on to have relapses every
one-two years. Those come out even by the repeated drugs stops after a period
of well-being. This case does to suggest a like-epileptic illness with pure
psychic expression (a probable epileptic depression).
Key words: Atypical depression,
derealisation, stress, epilepsy, EEG, theta waves, beta waves, epileptic
depression, drug therapy, amitriptyline, carbamazepine, benzodiazepine.
Drug modulation of stress reactions
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After I published three cases of
recurrent atypical depression as possible epileptic depression (Cocchi 2004; Cocchi
2004; Cocchi, 2005), I Have tracked down an other one, of a woman under
intermittent drug therapy since six years, coming to the last checkup on
September 2004.
Even this is a case deserving interest for
peculiar features for the history, psychopathology and EEG examination. Its
report, as the following, becomes the fourth of what appears as a little
series.
The case history.
A woman of 36 years, married, with a son.
Born from a prolonged delivery (72 hours since the beginning of first pains), enlarged
head in neonatal period following the delivery stress. The birth weight was
3800 grams.
August 1998, the first consultation. While
she was by the sea since July, she had sudden impression of polluted ground for
germ warfare.
Symptoms of fluctuating half-brain
dominance: To the test "Which
is the opposite of the colour Red?", she answers: The Green one. She is
not the Contrary Mary. Often she is using to count things without any need.
Stress symptoms: She is thinking too much, with fluctuating intrusive
thoughts. When tired, she loses the control of his thoughts. Her concentration
does not work, or only with difficulty. She suffers from the heat. Because a
refusal of her stomach, she cannot have breakfast before nine and half - ten in
the morning. When she is doing well, she eats gladly sweet things, but not the
meat or the cube broth. Any preferred diet does not occur, but the milk gives
her bother to the bowel. When sleeping, she doesn't talk, does not have
drooling, and. Differently of her past, she does not suffer from muscular
cramps. No hyperactivity occurs. Colic and diarrheas happen for no reason. No
bruxism reported but hands oversweating. Sometimes feelings of unsteadiness or
of fainting occur.
Depression symptoms: Since three nights she could not sleep. She never
had maniac episodes. No mediastinal oppression and the lump in the throat
occurred. She does not stand light, noise and confusion. Now she is crying, but
not often. Usually she is swallowing some air and then she belches it.
Other: She had a similar episode when she was 26. Sometimes she has the
feeling that the objects dilate or narrow down. When she was in the school, she
did better mathematics. Her hair is dry. Her menstrual cycle is longer with a
severe premenstrual syndrome.
Test therapy (daily doses, by the oral via):
Pyritinol 100mg, Pyridoxine 150mg, Haloperidol 0.5mg; Amitriptyline 10mg +
Perphenazine 2mg; Bromazepan 1.5mg; Valpromide 300mg; Carbamazepine 200mg.
September 1998, the first checkup after 28
days of therapy. She is doing better from a physical point of view. Now,
usually she sleeps, but not always. The fluctuating intrusive thinking reduced.
She did not take the haloperidol.
No therapeutic variation, but the
haloperidol is inclusive.
First days of June 2000, the second checkup.
She continued the drug therapy for about one year, then she hanged it by
herself because she was doing well off. Now, she has difficulty in falling
asleep. Since some months she is irritable. The appetite is well, but she has
stomach ache.
Therapeutic variation (daily doses, by the
oral via): Hanging amitriptyline + perphenazine and substituted with
Amitriptyline 16mg + Chlordiazepoxide 8mg.
Half June 2000: She can sleep only with the
addition of 2mg lorazepam, which she already took in past. Now, she forgets
things and she feels much confused. She had some weeping. Always, she has much
difficulty in falling asleep.
The new prescription (daily doses, by the
oral via): Hanging Valpromide, Bromazepam, and Pyritinol. I prescribed Oxcarbamazepine
300mg; Choline Alfoscerate 400mg; Pyridoxine 150mg; Lorazepam 2mg; Haloperidol
1mg.
Half July 2000: Now, she is doing well, but
she speaks too much and she wants do too much things (a jatrogenic hypomaniac
episode?). The appetite is good and her bowel function is regular. The
stomachache missed. She feels her head less blocked by intrusive thoughts.
Therapeutic variation (daily doses, by the
oral via): Oxarbamazepine 450mg.
April 2001; She had a well recover, for
which she stopped the drug therapy at the end of the preceding year. Recently.
She consulted an other psychiatrist for derealisation's thinking, and he
prescribed (daily doses, by the oral via) haloperidol 3mg and orphenadrine
50mg.
Now anxiety came out again, and she is
sleeping too much. Moreover, she inclines a little to slow down in the motility
that in the language (an effect of the haloperidol?). She affirms that she was
grown fat, and this gave her bother. With the new regimen she is less blowing
up.
Therapeutic variation (daily doses, by the
oral via): Haloperidol 2mg; Orphenadrine 50mg; Bromazepam 1.5mg.
EEG examination: Low voltage alpha
rhythm, stable, asymmetrical and poorly reacting, on which are inserted rapid
activities particularly evident in the occipital areas. Besides it there are
theta and delta waves sequences, mainly frontal and in the right half-brain.
EEG-mapping: Graphic elaborations as done
by epoches of 2 and 8 seconds. Power scales: from 0 to 28.8 (for epoches of two
seconds) and from 0 to 22.4 ( for the epoch of 8 seconds). There are ocular
artifacts.
The examination of powers of the four
frequency bands pointed out:
- Light increasing power, anomalous, of
the delta band, symmetrical, spread on the 8 seconds' epoch, of doubtful
pathological meaning;
- Moderately increased power, anomalous,
and probably pathological, of the theta band, partial, from both-sided frontal
zones to the parietal area on the left, and to occipital area on the right,
with the major increase in the back frontal zones;
- Anomalous and pathological distribution
of the power the alpha band, diffused, prevailing in the right half-brain and
with evident reduction of the normal occipital accentuation;
- Definitely anomalous and pathological
increasing of power of the beta band, diffused, asymmetrical, with prevalence
in the right side, accentuated in the occipital areas, and with a power peak in
the right occipital region.
End May 2001: She is better, but, as usual,
she reduced by her initiative the drugs because she was too sleepy. Now her
regimen is (to daily doses, by the oral via): Bromazepam 0.75mg; Haloperidol
1mg; Orphenadrine 50mg. She is more active and more calm. Recently she had
prolonged weeping, but she succeeds to speak more.
Therapeutic variation (daily doses, by the
oral via): Haloperidol 1mg; Orphenadrine 50mg; Bromazepam 0.75mg; Carbamazepine
100mg.
March 2003. As usual, she has hanged the
therapies, at the end of June 2002, because she did well off and she deluded
that she was definitely healthy. Since 10 days she has a relapse, with anxiety
and depression, downfall ideas related to her husband work. She consulted a
general practitioner physician who, waiting my checkup, prescribed her
injections of delorazepam 2mg, one in every day. She lost her appetite and she
became again constipated.
The new regimen (daily doses, by the oral
via): Delorazepam 2mg; Carbamazepine 100mg; Amitriptyline 10mg + perpfenazine
4mg, Polyvitaminic with mineral salts, one tablet for 10 days.
April 2004. Since 15 days she has a new
relapse. She would do too for everybody. Now, she has difficulty to elicit the
words, but she does not incline to stay home, where she doesn't succeed to do
anything. Often she has a dental shut. The dentist prescribed a bite. Usually,
she sleeps for 5-6 hours, then she gets up for eating or smoking. She eats
anything, bread, sweet things, etc. She forgets easily. Her eyes go to close.
She has intrusive thoughts, and restarted to count, mainly backwards. Some
constipation occurs. Her breakfast is early morning. In the summer 2003 she
suffered from hot weather, but in Italy it was very hot. The menses are
abundant and she has a premenstrual syndrome, for which she consulted a
gynaecologist. Often she cries. Nighttime muscular cramps do not occur as well
as drooling during her sleep. In this period she does not remember her dreams.
Her current depression did not follow family problems or other external causes.
She currently takes (daily doses, by the
oral via): Delorazepam 2mg; Carbamazepine 200mg. Of his initiative, she stopped
Amitriptyline + Perphenazine, because she recovered her sleep problems [??].
Therapeutic variation (daily dose, by the
oral via): S-adenosil-l-methionine 200mg; Pyridoxine 75mg; Carbamazepine 300mg;
Delorazepam 2mg; Amitriptyline 10mg + Perphenazine 2mg.
End September 2004. At the end of June,
since she was doing well, again she stopped any therapy. Since 10 days she
resumed it because she missed had a lack of strength, became irritable, did not
succeed to do anything. At night, when she loses her sleep, she gets up for
eating and to smoking. From her mother, during that consultation, I learned
that there has been some familiarity for the depression.
She goes on with the current therapy.
Discussion.
Even in this person, the depression is
atypical and recurrent. From time to time she has sudden mood fall, even with
downfall or prosecuting ideas, or derealisation feelings.
The EEG examination acted in 2001, showed
marks of "irritability," probably to get in touch with her prolonged
and complicated delivery. Even here the temporal areas are involved, but even
the frontal and the occipital ones.
The intolerance to the light, could be a
mark of irritability of the occipital brain areas. These psychic phenomena can
rarely relate to stressful events having a switching function. In fact, there
was an excess of light stimulation and iodine air by the sea, at the moment of
the interpretative episode that drew her to the first consultation, in August
1998.
In this patient too we can observe the features
of:
- Change of the mood, in recurrent and fit
ways, which may longly last (weeks or months);
- Lack of link with external and clearly
identifiable causes;
- Altered EEG, but not meaningful for
epilepsy;
- Good response to the antiepileptic and antistress
drugs.
There were not any positive variations of
the personality following the drug therapy (Cocchi 2004; Cocchi 2004; Cocchi
2005) because the patient does not take it longly, and stops it shortly
afterwards shed had an improvement.
In this case I cannot speak of poor response
to the serototoninergic tricyclic drugs, because these drugs always ran both on
the mood and the sleep induction.
There are symptoms of fluctuating half-brain
dominance, even for the need of counting, as confirmed in 2004, when she said
of having restarted to count, mainly backwards.
Conclusions.
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.
Here it was a prolonged and complicated
delivery, while, in the three preceding cases, two complicated deliveries and a
meningitis at five years. Moreover, the temporal areas of the two half-brains
have EEG marks of "irritability." The trouble is expressed in psychic
way, mainly depressive, with sporadic derealisation phenomena.
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>.
Posted on internet on 2 February 2005. Copyright by Renato Cocchi, 2004.
Author's address: Dr Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia