66. Blogathon: “Dear Diagnosis”

7 November 2013 at 23:34 | Posted in Circadian rhythm | 5 Comments
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Julie Flygare, the author of  Wide Awake and Dreaming: A Memoir of Narcolepsy, is hosting «Dear Diagnosis»,  a blogathon where she invites «all narcolepsy and chronic disease bloggers to write a letter to yourself on your diagnosis day.”  To date, all responses are from narcolepsy bloggers.  She needs one from another chronic disease blogger, I think. 

Dear me in April 2004,

Elation!  Finally a doctor who recognizes that you are not (just) lazy and inconsiderate.  He understands so well that he asks about things you never realized were connected to your sleep problems.  He asserts that you have a valid condition and even has a name for it:  Delayed Sleep Phase Syndrome, which in years to come will be “uprated” to Delayed Sleep Phase Disorder.

Yes, you are on a high which will last several months, in spite of the fact that the treatment he recommends doesn’t really work.  Thanking the heavens for the Internett, you will research DSPS and discover that its been known (but only to  chronobiologists, apparently) for over 20 years.  You will fill a couple of ring binders with scientific studies, learning to read and understand them along the way.

That overnight sleep study at the hospital in the early ‘90s that came up with “not narcolepsy” as a diagnosis should have rung a bell for that neurologist!  Curses on him.

It will, unfortunately, take years for you to stop blaming it all on your own lack of self-discipline and to (re)gain some self-esteem.  You will still have to make sincere apologies when you are late for work and miss appointments.

You will foolishly refuse to accept 100% disability when it is offered, going along with your GP who feels you should at least keep working part-time for social reasons.  So you’ll be 40% disabled for a while, then 60%.  Retirement age comes as a great relief.

You will actually start a blog about DSPS, partly for yourself but also in hopes of helping anyone who stumbles upon it.  You’ll hear from thankful people; it’s great to be appreciated!  You’ll find a wonderful support group, “niteowl”, online where intelligent and helpful people help each other learn.  You’ll find other fora where you can help people.  You’ll eventually start a wiki, then be a part of starting a non-profit, Circadian Sleep Disorders Network, to provide support, inform and try to spread awareness.

Your sleep specialist (yes, the same one as today)  will tell you: “Now you can hang out a sign and start taking patients.”  He’s joking, of course, but it’s a nice compliment.

In sum, your life will continue to center in large part around your sleep problems, as it always has, but increasingly in a positive way!

Best wishes,

Me in 2013

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Next post:  67.  ~coming soon~

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63. Sleep research in the USA

12 May 2011 at 19:25 | Posted in Circadian rhythm | 6 Comments
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Funding of sleep research by the National Institutes of Health (NIH) is prioritized according to the National Sleep Disorders Research Plan.  The plan resulted from 1993 legislation establishing the National Center on Sleep Disorders Research with the mandate, in part, to:

  • Conduct and support research, training, health information dissemination, and other activities with respect to a basic understanding of sleep and sleep disorders, including research on biological and circadian rhythms, chronobiology, and other sleep-related topics.

The first such plan was dated 1996.  The second and current one is from 2003:  http://www.nhlbi.nih.gov/health/prof/sleep/res_plan/sleep-rplan.pdf  

The present Sleep Disorders Research Advisory Board, chaired by Charles A. Czeisler and with Michael Twery as Executive Director, has been working for a year or so on a revision.  The 2011 research plan will provide a guide for future scientific sleep and circadian research, both basic and clinical.

While the 2003 plan is organized under such headings as Basic sleep science, Enabling technology, and Pediatrics, the 2011 plan will be organized around research goals.

The draft of April 2011 contains five goals.  They are concerned with, in short version:

  1. Sleep and circadian functions and mechanisms
  2. Factors contributing to sleep and circadian disorders and disturbances
  3. Prevention, diagnosis and treatment of sleep and circadian disorders and circadian disruption
  4. Dissemination of sleep and circadian research findings
  5. Sleep and circadian research training, to accelerate the pace of discovery

There appears to be a greatly increased emphasis on circadian disorders and research in this draft.  The word ‘sleep’ appears seldom alone; it’s always ‘sleep and circadian’.

Those of us with circadian abnormalities are perhaps most happy with goal 4.  Health care professionals, educators, policy makers and the general public are at present largely unaware of the results of research to date, and the resulting ignorance leads to misdiagnosis of most of us.  The research community knows a great deal more than the medical community does, and dissemination of that knowledge should have high priority.

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Next post:  64.  Circadian Sleep Disorders Network

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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)

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Next post:  63. Sleep research in the USA

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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.

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Next post: 60. Charting the Course of N24

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xlviii. Guest blogger: Breann (again!)

24 January 2010 at 21:48 | Posted in Circadian rhythm | 4 Comments
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  The  body  clock

 

A new list member wrote that his wife doubts the validity of Delayed Sleep Phase Syndrome, believes that his diagnosing doctor is a quack and believes that forcing oneself up early – often enough – will solve the problem.   

Breann, with her knowledge of biology, responded:

Hi __, nice to meet you 🙂

It might help if your wife had a basic understanding of genetics. I’m not trying to be flip, many people don’t; they’re lucky if they get some Mendel in high school, and unfortunately, his “one gene, one trait” discovery is not true for everything. (The last time I checked, there were at least ten genes thought to be involved in the sleep-wake cycle. Whew!)

In my experience, it has simply never occurred to most people that they wake up or go to sleep for any reason other than being tired or not being tired; i.e. they believe it is mostly a conscious choice. They are unaware that their body has many complex and delicate systems keeping track of the time of day, how long they’ve been awake, how much or little food they’ve consumed, and so forth. Sometimes just teaching people that these seemingly simply urges aren’t TRULY conscious choices for anybody is a great help in their understanding that some or all of these systems can “go haywire” due to using a different set of instructions (different forms of the genes that regulate the processes).

Something that really worked with my friends and family was for me to simply sit them down and ask them flat-out: “You have known me my whole life. Do I seem like the kind of person who is going to malinger for decades just to get out of doing things that you KNOW I enjoy doing? Think about this logically. Am I that kind of person? Do you think I’m faking when I’m upset about getting fired, or missing an important appointment? Either your judgement of me over the last 20 years is totally wrong, or I am insane and need a lot more help than a sleep doctor.”

That flipped a light switch for them, I think. It was still hard for them to accept, and still is in some cases, but it at least got them to consider the fact that if there isn’t something wrong with me physically, than that leaves me as someone who has deliberately, yet unconsciously, set out to ruin my own life. That makes no sense, if they take a minute to think about it, and not just have a knee-jerk reaction.

Hope this helps!

–Breann

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Next:  xlix. 2009:  sleep logs

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