DSPS, a sleep disorder

62. Psychiatric misdiagnosis of N24

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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