62. Psychiatric misdiagnosis of N24

31 March 2011 at 05:27 | Posted in Circadian rhythm, Melatonin, N24 | 21 Comments
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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 (James Fadden)


Next post:  63. Sleep research in the USA



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  1. 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.

  2. 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 🙂

  3. 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.

  4. 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.

  5. 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.

  6. 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.


  7. 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?

  8. 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.

  9. 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.

  10. That is a very interesting observation.

  11. I saw Dr Dagan who wrote that paper. He did not help me. One thing he did say was that he thinks there is a link between delayed circadium rythm disorder (what he diagnosed me with,) and fertility problems. He asked me if I had any fertility problems. “None” I answered, as I never tried to get pregnant. Just few years later I develped ovarian cysts (constantly forming), 3 torsions of the ovary, heavy periods. He said nearly every woman he sees has some fertility problem with their sleep cycle disorder. I so wish he would stop keeping this idea in his head and write a paper on it.

  12. Hello Rachel,
    I have read that it was once considered to make birth controll out of (or with) melatonin, as it reduces the chance of ovulating. For the same reason, it can mess up your periods. It’s still recommended to not take melatonin when one is trying to conceive. But that is the only connection I’ve ever heard of between fertility and melatonin in humans.
    It seems unlikely that it could have caused your problems, but who knows; there’s not nearly enough research done on circadian rhythms!
    You’re right, of course; if Dagan knows something, he should publish.
    Best wishes and thanks for writing.

  13. When you dont wear the watch and say leave it on a surface will it just show that ur a sleep or that youve taken it off?

  14. It will show no movement which would normally be interpreted as sleep. However, doctors will usually ask you to note down any time you have to take it off so this can be taken into account when interpreting the data.

  15. R u sure? as on the actiwatch website it says it will show off wrist activity with a navy blue line :&

  16. The blue lines are event markers. The actiwatch has a event button. You push it and it records the time, which then shows up as a blue line when the results are charted. Usually you are asked to push the event button when you get up and when you go to bed. The blue lines do not appear unless you hit the event button, so they would not indicate off-wrist activity (unless you deliberately pushed the button to indicate that.)

    Along with the watch you are given a written sleep diary to fill out. It includes boxes to write when you removed the watch and when you put it on. Otherwise a short period of having the watch off would look like a short episode of sleep. (Longer periods of sleep will show at least a little movement in most people.)

  17. So my results are just going to look like the graph above?

  18. Everyone’s results will be somewhat different, but if you have N24 it will usually show a similar pattern. Even within N24s there is a lot of variation.

  19. I think the individual patterns of free-running depend on not only physiological mechanism, but also psychological.
    I sometime shifted another time zone during free-running.
    It is called as jumping.
    It occurred, when I kept awaking with a strong determination to fulfill my business in time.
    Sleep-wake cycle is regulated by circadian rhythm, homeostasis and emotion.

  20. Or, as sleep researcher David Dinges said:
    ” …we’re the only animal that volunteers for sleep deprivation… ”
    (That may not be entirely a propos, but I love the quote.)

  21. I just re-read this post and got angry all over again. I am sure that the last paragraph quoted oversimplifies the boy’s situation and paints it all too rosy. He’s been tortured since he was 10-years-old by specialists, school, family and, for three months, “an inpatient child psychiatry center!” And we are expected to believe that he’s a normal, well-adjusted 14-year-old? Hardly. He may well have PTSD.
    I could scream at the lack of competence and even common sense shown here.

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