62. Psychiatric misdiagnosis of N24

31 March 2011 at 05:27 | Posted in Circadian rhythm, Melatonin, N24 | 9 Comments
Tags: Adolescent, Depression, Diagnosis, Non-24, Sleep disorder, Treatment

I’ve been reading an interesting article on a case of psychiatric misdiagnosis of N24 in a 14-year old. This poor kid was given a long list of severe and pejorative psychiatric diagnoses, all of which resolved completely when his circadian rhythms were normalized with melatonin treatment. He had dropped out of school for two years and was sent to a child psychiatric hospital. After treatment was able to return to school and do well. This case shows how easily N24 (and DSPS) can be misdiagnosed. The boy was also lucky he responded to melatonin as many N24s do not.

Here is the description of his case before proper diagnosis and treatment:

During the 4 years before referral,
the patient suffered from major functioning difficulties
including conflicts with teachers, parents, and peers. He
was described by a licensed child psychologist as being
extremely introverted with severe narcissistic traits, poverty
of thought, and disturbed thinking, including
thoughts with persecutory content and self-destruction
that led to a paralyzing anxiety, anhedonia, social isolation,
and withdrawal. Assessment of learning disabilities
revealed difficulties with written language and poor
visual and auditory memory. Assessment also revealed
above-average performances in verbal comprehension
and abstract reasoning.

Two years before referral, the patient dropped out of
school and was sent to an inpatient child psychiatry center.
Three months of psychiatric evaluation yielded diagnoses
of atypical depressive disorder with possible
schizotypal personality disorder. He was described as
sleepy and passive, especially in the mornings.

The patient was diagnosed using actigraphy (a wrist monitor that measures movement) and with 24 hour sampling of melatonin and temperature rhythms. This is his actigraphy chart showing the classic N24 pattern in which the waking period shifts later each day. The black peaks on the chart show movement, indicating the time of day or night during which he was awake.

Treatment with 5mg of melatonin (a large dose) at 8pm resulted in a normalization of his circadian rhythms within a month.

Here is how he was described after proper diagnosis and treatment:

The patient returned to school after a 1 years absence
and succeeded in filling the gaps of missing studies. At the
end of the first semester, his school report showed excellent
results. His parents also reported an improvement in
the patients relationship with his family and peers.
In a psychiatric evaluation by licensed psychiatrists,
none of the previously described severe diagnoses were
present, and the boy showed no evidence of psychopathology,
as was previously thought.

One wonders how many adolescents — and adults — are misdiagnosed with various severe psychiatric disorders simply because no one looked for a circadian rhythm sleep disorder. The case was reported by Yaron Dagan and Liat Ayalon two of the best researchers on the clinical manifestations of N24 [1].

1. Dagan Y, Ayalon L. Case study: psychiatric misdiagnosis of non-24-hours sleep-wake schedule disorder resolved by melatonin. J Am Acad Child Adolesc Psychiatry. 2005 Dec;44(12):1271-5.

–Posted by LivingWithN24

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Next post: 63. Sleep research in the USA

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My DSPS was diagnosed as an “Anxiety of leaving home” by shrink. I was sent to him by my doctor when I complained that I can’t sleep. He was funny, I didn’t go third time.

Comment by braveslice— 11 April 2011 #
Oh I have to add that my brother is a doctor and even though I have send him many links he still don’t believe that there is a thing called DSPS at all

Comment by braveslice— 11 April 2011 #
Yeah, you can hear anxiety and other mental diagnoses from psychiatrists, psychologists and even ordinary doctors. We’ll have to hope that education in medicine is improving. It is a good sign in that regard that there is a new, one-year subspecialty in sleep medicine in the USA.

Comment by delayed2sleep— 11 April 2011 #
In my experience, doctors dismiss anything one finds on the internet. When the internet became popular in the mid 90′s, the medical field was one of the last “industries” to adopt and use it. And I still rarely see a doctor using a computer. I think we overrate and expect too much of the profession. But, that makes it even more important for us to advocate.

Comment by brian mcdoh— 1 May 2011 #
I appreciate your introduction.
I also took many years until diagnosed as non-24.
Psychiatrists misdiagnosed me as depression or bipolar affective disorder.
Moreover, they attributed my disease to student apathy or difficulty of personality, when I did not respond to their treatments.
It is an only way to receive an appropriate treatment, I think, we have to complain our badness for years.

Comment by Free Runner— 14 May 2011 #
Thank you for your comment, Free Runner. Many of us with N24 are misdiagnosed for years before receiving the correct diagnosis. You are correct that we have to be persistent in our complaints to get the right diagnosis and treatment.

I noticed that you are posting from Japan. I am glad to see that since there is a lot of N24 research published in Japan (for example, Dr. Kiyohisa Takahashi has published a number of papers on DSPS and N24). But it sounds like most physicians there are still unaware of these conditions.

–LivingWithN24

Comment by livingwithn24— 14 May 2011 #
My problem is that when I take melatonin I have the most horrible nightmares, vivid dreams, panic, waking up sweating, etc. I dont have any of that unless I take melatonin or tranquillizers and antidepressants. I have tried a hundred times and I always get the same result soI cant even go for two nights in a row after such horrible experience. Anyone else?

Comment by dwils— 24 July 2011 #
dwils,
I don’t have that reaction to melatonin, but I have heard of a few other people who have similar reactions. I sometimes find that melatonin can make me sluggish or a bit depressed. Nightmare and waking in a panic do happen to some people, so you are not alone in that.
-LivingWithN24

Comment by livingwithn24— 3 August 2011 #
I know the following Wiki excerpt about Lithium sounds way too technical but the mention of lithium treatment in terms of “disrupting” the circadian clock and the master clock really caught my interest. I started taking Lithium Oratate 3 weeks ago and am now sleepy at 3 am, awake with the alarm. Before that I was starting to sleep later and later, 6 am, 7 am, and knew I would go around the clock eventually. Please read below,

“An unrelated mechanism of action has been proposed in which lithium deactivates the GSK3β enzyme.[33] This enzyme normally phosphorylates the Rev-Erbα transcription factor protein stabilizing it against degradation. Rev-Erbα in turn represses BMAL1, a component of the circadian clock. Hence lithium by inhibiting GSK3β causes the degradation of Rev-Erbα and increases the expression of BMAL which dampens the circadian clock[34] Through this mechanism, lithium is able to block the resetting of the “master clock” inside the brain; as a result, the body’s natural cycle is disrupted. When the cycle is disrupted, the routine schedules of many functions (metabolism, sleep, body temperature) are disturbed. Lithium may thus restore normal brain function after it is disrupted in some people”.

This might be a good med for DSPS and N24. Lithium Orotate over the counter is a much lower dosage than prescribed lithium carbonate, I take 1 tab lithium orotate 3x per day, (120 mgs, 4.8 mg elemental lithium per tab). I make sure I take 1 at midnight. A 3 month supply costs $12. That’s why there is no research on it, it is just a mineral, very cheap and very available. It’s working for me.

Comment by Judy— 16 November 2011 #

DSPS, a sleep disorder