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


59. Clock genes at the heart of depression

24 October 2010 at 02:25 | Posted in Circadian rhythm | 8 Comments
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Which came first: the chicken or the egg?  The circadian rhythm dysregulation or the depression?

Traditionally, it has been claimed (assumed) that depression causes sleep problems including sleeping too early (the thinking in the 1980s) or too late (more recently).  We who have circadian rhythm disorders (CRDs) have always thought that depression and other mood disorders can be a result of circadian rhythm misalignment or disruption, rather than a cause.

Now a review* suggests that polymorphisms in some of the 18 clock genes may cause both depression and CRDs.

  • [T]reatment strategies or drugs aimed at restoring ‘normal’ circadian rhythmicity may be clinically useful.
  • [W]e may predict that new antidepressant drugs will emerge that (…) target and correct abnormalities in the circadian timing system. 


A recent careful study of patients with delayed sleep phase syndrome (DSPS) showed that

  • patients who also showed depressive symptoms had an even later peak in the 6-sulphatoxymelatonin rhythm than patients with no depression. 


Even research on rodents provides evidence

  • for a role of clock genes in behaviours that are relevant to mood disorders.


Much of the genetic info in this review goes way over my head, but this bit sounds reasonable:

  • The endogenous rythmicity within the master biological clock in the brain … is generated by interlinked positive and negative feedback loops of gene transcription and translation.  If there is to be a role of circadian rhythmicity in mood disorders then it almost certainly involves these genes….


Practical results?

I’m hoping that these ideas represent a turning point in circadian rhythm research.  I hope that, here on in, the researchers search for realistic and practical treatments, as well as useful diagnostic tests, for CRDs.


* Kennaway, David J. (2010) Review: Clock genes at the heart of depression.  Journal of Psychopharmacology Vol. 24 No. 5

The illustration is borrowed from a blogpost by Jeff Pruett.


Next post: 60. Charting the Course of N24


xxii. How to tackle DSPS

18 December 2005 at 12:48 | Posted in Circadian rhythm | 6 Comments
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Having a circadian rhythm disorder and not knowing what it is, is essentially different from having one and knowing something about it.  Though no two of us are alike, anyone with a disorder related to mine who has read this far, now knows something about it.  
Someone wrote on a message board recently:  “Wow – reading these posts is totally shocking.  It seems like I have written them all myself!  I have gone through so much of what is described here.” 
Adding such descriptions here, blog entries about my past troubles and struggles, already half-written in my head, is unnecessary, I think. 
Finally — way out in the middle of Chapter Two — it’s occurred to me that I should define who I’m writing for. 
You are probably over 20.  You have one heck of a time getting up in the a.m. no matter how many alarm clocks you are using (and likely not even hearing).  You are at your most alert, creative, productive and alive in the middle of the night, and you’ve been like this for years.  You’ve tried “getting to bed at a decent hour”, but for you that doesn’t mean getting to sleep right away.  However, when timed right for you, your sleep is usually good and uninterrupted for 7-9 hours.  When you do get enough sleep, timed right, you’re not unreasonably tired the rest of the day.  You suspect that you may have a circadian rhythm disorder. 
You may also be one of the approximately 50% of us who’ve been diagnosed with depression or anxiety.  Not all the experts agree with me ( yet Image ), but it looks like the trend is to accept that the root of the problem is the physical / chemical / genetic circadian rhythm disorder.  The mood problems follow, quite logically, because of societal expectations and pressures, often compounded by sleep deprivation. 
You may have gotten onto the sleeping pill merry-go-round, resulting in habituation, withdrawal, rebound etc.  (Thanking my lucky stars — I’ve never gone to a doctor who talked me into that!) 
You may have developed all manner of coping strategies, for example sleeping in two shifts every day. 
So what do you do now?  
You live with it, or you go for diagnosis and maybe treatment.  I want to talk a bit about these options, but first:  The Sleep Log.


Next post:  xxiii. We interrupt this program…


xi. My diagnosis!

27 November 2005 at 04:22 | Posted in Circadian rhythm | 7 Comments
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 (No, this isn’t my sleep specialist, but he does look like him :-))

Through a 15 year period, my present doctor had tested me for thyroid etc., sent me to a neurologist for overnight sleep analysis with all the attached equipment, sent me to a series of time-consuming and useless psychologists, had my throat operated (probably unnecessarily) for apnea and put me on a pill for depression.
Finally, he said he wanted to send me to a specialist to see if the depression diagnosis was correct.  The specialist he chose is a professor of psychiatry and the co-founder of a sleep clinic where he works one afternoon and evening a week.  I feared, and fully expected, a new and expensive round of psychologist-type time-wasting.
Dr. Holsten asked the many questions you’d expect to get from any new doctor:  health, job, living arrangements.  A great many questions, very quickly.  I should have taped the interview so I could analyze at what point it dawned on me that these aren’t questions to just any and every patient — this guy is circling me in!  He asked unexpectedly about several things which applied to me, but which I’d never connected to sleep problems.  It was rather exhilarating, like the experience some people rave about after having their fortunes told.
Unlike most doctors today he wasn’t staring at a computer screen, but he wasn’t looking at me either.  He was placing dots on a tiny grid about 8×10 cm.  Suddenly he looked up and said “You have DSPS!”  Of which I’d never heard.  He drew curves showing the timing of normal sleep related to body temperature, said he’d have my regular doctor put me on 100% sick leave for two months, gave me a sleep diary form to fill out every day, wrote the application and prescription for melatonin, arranged for me to borrow a light box, gave instructions (NO naps!), said it wouldn’t hurt to keep taking the depression medication and made an appointment for the first follow-up three weeks later.  I was out of there within 30 minutes with my head swimming.
Next post:  xii. Circadian rhythm disorders

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