Interface of panic and depression: clinical and sleep EEG correlates

Four groups of subjects were compared with respect to their clinical and demographic status and electroencephalographic (EEG) characteristics, namely: primary major depressive disorder (PRI MDD); panic disorder (Panic); "Mixed" group comprising patients meeting full syndromal criteria for MDD and panic occurring concomitantly; and normal controls. The "Mixed" (MDD + Panic) patients were characterized by earlier age of onset of psychiatric illness, longer duration of current episode, greater intensity of symptoms, higher impairment of functioning, increased miscellaneous psychopathology, and greater objective stress and anger. With respect to sleep EEG variables, PRI MDD patients were clearly different from the other three groups. The sleep profile of the "Mixed" group occupies an intermediate position between the "pure" Panic and MDD groups. Classification of the "Mixed" patients based on the discriminant function coefficients of the Schedule for Affective Disorders and Schizophrenia and sleep analysis of the "pure" groups (PRI MDD and Panic) reveals that some patients are classified as true PRI MDD while others are classified as falling somewhere along the PRI-MDD/Panic spectrum. The separation of the PRI MDD from Panic and Normals, however, is clear, suggesting that sleep can be successfully used as a physiological marker in the separation of these conditions.     

Prevalence and correlates of alpha-delta sleep in major depressive disorders

Objective. Major depressive disorder is associated with sleep disturbances. An electroencephalographic pattern of alpha wave intrusion in delta wave sleep (alpha-delta sleep) is observed in some subjects with major depressive disorder. The treatment-resistant symptoms in major depressive disorder, nonrestorative sleep and fatigue, are associated with alpha-delta sleep. The objective of this study is to identify the prevalence and clinical correlates of alpha-delta sleep in major depressive disorder.Design. Retrospective studySetting. Sleep Disorders Center, Cleveland Clinic, Cleveland, OhioParticipants. Polysomnograms were conducted on 150 subjects 18 years of age or older (75 with and 75 without major depressive disorder) were reviewed.Measurements. The percent of delta waves with alpha intrusion was collected and analyzed.Results. Subjects with major depressive disorder compared to nondepressed subjects had a higher sleep efficiency (83.0±9.6; 78.1±8.2%), shorter rapid eye movement latency (85.0±44.5; 189.9±25.6 min), less slow wave sleep (8.3±3.0; 13.5±6.2%), and greater rapid eye movement (24.7±7.0; 19.2±8.2%), and all of these findings were statistically significant. Patients with major depressive disorder had higher alpha-delta sleep (23.4±14.2%; 2.3±6.7%, p<0.01). Patients with major depressive disorder were categorized into high and low alpha-delta sleep based on percentage of alpha-delta sleep present in slow wave sleep (alpha-delta sleep was present ≥15% or ≤15% of slow wave sleep, respectively). Patients with major depressive disorder with high alpha-delta sleep were at 3.15 greater odds (1.22-8.14; p=0.018) to have excessive daytime sleepiness.Conclusion. Patients with major depressive disorder have a higher prevalence of alpha-delta sleep. Alpha-delta sleep is associated with daytime sleepiness in patients with major depressive disorder. Study limitations include the retrospective nature of the project and the fact that the principle investigator, who scored and interpreted alpha intrusion, was not blind to group membership.     

Delimitation of generalized anxiety disorder: clinical comparisons with panic and major depressive disorders

We compared 40 outpatients with "pure" generalized anxiety disorder (GAD) with 152 panic disordered patients with varying degrees of phobic avoidance, and 241 primary major depressives with single and recurrent episodic patterns. Despite sociodemographic and symptomatologic overlaps with these comparison groups, GAD emerged as a relatively distinct disorder, characterized by chronic low-grade symptomatology with observed anxiety at interview, as well as nausea, headache, tension, and insomnia. These anxious "traits," which appear to be part of the habitual self of the patient, are subject to fluctuation over time, and may form the temperamental substrate or precursor of panic and other anxiety and depressive disorders.     

Simultaneous panic and depressive disorder: response to antidepressant treatments

Recent publications have stressed the relevance of the simultaneous panic disorder and major depressive disorder (MDD) diagnosis from various aspects, including clinical, therapeutic and prognostic, incidence of family psychopathology, and biologic differences. Treatment outcome measures (Hamilton Depression Rating Scale scores and treatment response) were compared in two groups of patients; one group had MDD alone (N = 8) and the other had simultaneous panic disorder and MDD (N = 8). Patients with MDD alone responded significantly better to antidepressant treatment.     

Familiality and clinical outcomes of sleep disturbances in major depressive and bipolar disorders

Objective

Sleep disturbances are frequently observed in major depressive (MDD) and bipolar disorder (BD). This study reported sleep profiles of patients and their relatives versus controls, and examined the familiality of sleep features in mood disorder families. We also evaluated the influences of sleep disturbance on patients' quality of life (QOL), functional impairment, and suicidality.

Methods

We recruited 363 BD and 157 MDD patients, 521 first-degree relatives, and 235 healthy controls, which completed a diagnostic interview, Pittsburgh Sleep Quality Index (PSQI), and QOL questionnaire. The magnitude of heritability of sleep features was calculated and familiality was evaluated by mixed regression models and intraclass correlation coefficient (ICC). The associations between sleep problems and clinical outcomes were examined using multiple regression models.

Results

More than three-quarters of mildly-ill patients were classified as “poor sleepers”. MDD patients had significantly worse sleep quality as compared to BD patients. Moderate but significant familial aggregation was observed in subjective sleep quality, sleep latency, disturbance, daytime dysfunction, and global score (ICC = 0.10–0.21, P < .05). Significant heritability was found in sleep quality (0.45, P < .001) and sleep disturbance (0.23, P < .001). Patients with good sleep quality had better QOL and less functional impairment (P < .05) than poor sleepers. Poor sleep quality and nightmares further increased the risk for suicidal ideation (OR_adj = 2.8) and suicide attempts (OR_adj = 1.9–2.8).

Conclusion

Subjectively measured sleep features demonstrated significant familiality. Poor sleep quality further impaired patients' daily function and QOL, in addition to increasing the risk of suicidality, and thus requires special attention in related clinical settings.     

Immune cell imbalance in major depressive and panic disorders.

We investigated subsets of peripheral immunologic cells in 12 drug-free patients affected by major depression according to DSM-III-R criteria, and who had recent evidence of somatic diseases. They were compared with 10 drug-free depressives, with 10 patients with panic disorder, and with 12 healthy volunteers, all without somatic disease. The immune subsets were measured by flow cytometry. The results showed that both groups of depressives had the same abnormalities in immune cells compared with the healthy volunteers or the panic disorder patients; in particular they presented a lower number of CD3+, CD8+ and HLA-DR+. The patients with panic attacks did not differ from healthy controls, except for CD4+ cells which were significantly lowered, even in comparison with the depressive groups. These data, although preliminary and in a small sample, suggest that some immune parameters may be influenced by the presence of a major psychiatric disorder.     

Serial dexamethasone suppression tests in simultaneous panic and depressive disorders

Recent work suggests that the simultaneous occurrence of major depressive disorder (MDD) and panic disorder (PD) may be of relevance for clinical findings, therapeutic outcome, and prognosis. It is of interest to know whether or not this relevance extends to biological findings. We addressed this question through comparison of serial Dexamethasone Suppression Test (DST) results in patients who had either MDD alone or simultaneous MDD and PD. We were unable to describe differences between the groups.     

EEG sleep in non-affective psychiatric disorders

Several sleep complaints and disturbances have been documented in psychiatric disorders. These modifications of sleep in anxiety disorders, alcoholism, schizophrenia, dementia and eating disorders are reviewed and discussed. At the present time, there is no evidence for any specific sleep pattern in non-affective psychiatric disorders. The co-morbidity of sleep disorders like sleep apnoea, periodic leg movements and parasomnia in psychiatric illness is not very well known at the present time.     

Insight and correlates among outpatients with depressive disorders

The aims of this study were to explore the levels of insight in patients with depressive disorders and to examine the factors that influenced insight. Using the Mood Disorders Insight Scale, we evaluated 247 patients with depressive disorders to determine their levels of insight with respect to their awareness of the illness, the attribution of symptoms, and their belief in the necessity of treatment. The relationships between insight and the severity of depressive symptoms, the level of self-stigma, sociodemographic characteristics, and the course of the illness were examined. The results reveal that 91 (36.8%) subjects had impaired insight into awareness of their illness, 92 (37.2%) had impaired insight into attribution of symptoms, and 39 (15.8%) had impaired insight into the need for treatment. A younger age and more severe depression symptoms were significantly associated with insight into awareness of the illness. More severe depression symptoms and a higher education were associated with intact insight with respect to attribution of symptoms. Those who have a major depressive disorder were more likely to have intact insight into the need for treatment than those with depressive disorder that was not otherwise specified. Analysis of our results indicates that depressive patients with factors predicting impaired insight may benefit from intervention to improve their insight, and this should advance their recovery.     

Effect of preexisting borderline personality disorder on clinical and EEG sleep correlates of depression

Two groups of depressed patients were studied: (1) The first group comprised 15 inpatients who were diagnosed as predominantly “borderline personality disorders” based on DSM-III and psychometric test criteria; these patients were also clinically depressed. (2) The second group consisted of 18 inpatients who met Research Diagnostic Criteria (RDC) for major depressive disorder (MDD) but who failed to meet the above criteria for borderline personality disorder. Subsequent to the selection of patients for study, an independent diagnostic evaluation revealed that MDD patients with borderline personality disorder had higher ratings than nonborderline MDD patients on items from the Schedule for Affective Disorders and Schizophrenia such as total anxiety, anger, schizotypal features, miscellaneous psychopathology, and alcohol and drug abuse. A further breakdown of miscellaneous psychopathology items revealed greater subjective anger, self-pity, and demandingness in borderline patients. A comparison of RDC subtypes in the two groups revealed a significant increase in bipolar II diagnoses in the borderline MDD group. Electroencephalographic (EEG) sleep studies carried out in a subsample of MDD borderline (n=8) and primary MDD nonborderline (n=11) patients revealed no significant differences between the two groups. Thus, in contrast to the EEG sleep findings reported for secondary depression with other antecedent psychiatric disorders, the present study indicated that a preexisting diagnosis of borderline personality disorder in MDD patients did not alter the characteristics short latency of rapid eye movement (REM) sleep and the sleep continuity disturbances reported in primary MDD. These data confirm earlier reports by Akiskal (1981), Carroll et al. (1981), and McNamara et al. (1982) concerning the phenomenological and EEG sleep profiles of borderline patients.     

"Anger attacks": possible variants of panic and major depressive disorders

The authors report a series of illustrative cases in which patients presented with sudden "spells" of anger with physical features that resembled panic attacks but lacked the affects of fear and anxiety. These spells or "attacks" of anger were experienced as uncharacteristic and were inappropriate to the situations in which they occurred. Since treatment of these attacks with antidepressants produced in each case marked improvements in behavior, the authors also formulate some hypotheses as to the nature of these episodes.     

Self-stigma and its correlates among outpatients with depressive disorders

The aims of this study were to assess self-stigma among Taiwanese outpatients with depressive disorders and to examine the factors related to self-stigma. Using the Self-Stigma Assessment Scale, the authors evaluated 247 outpatients with depressive disorders to determine their levels of self-stigma. The relationships between self-stigma and severity of depressive symptoms, sociodemographic characteristics, and course of illness were further examined. Sixty-two patients (25 percent) had high levels of self-stigma. Patients who had more severe depression and less education had higher levels of self-stigma. Clinicians should take self-stigma into consideration when communicating with depressed patients, especially those with characteristics associated with high levels of self-stigma.     

EEG and behavioural correlates of mild sleep deprivation and vigilance

ObjectiveThe current study investigated the behavioral, cognitive, and electrophysiological impact of mild (only a few hours) and acute (one night) sleep loss via simultaneously recorded behavioural and physiological measures of vigilance.MethodsParticipants (N = 23) came into the lab for two testing days where their brain activity and vigilance were recorded and assessed. The night before the testing session, participants either slept from 12am to 9am (Normally Rested), or from 1am to 6am (Sleep Restriction).ResultsVigilance was reduced and sleepiness was increased in the Sleep Restricted vs. Normally Rested condition, and this was exacerbated over the course of performing the vigilance task. As well, sleep restriction resulted in more intense alpha bursts. Lastly, EEG spectral power differed in Sleep Restricted vs. Normally Rested conditions as sleep onset progressed, particularly for frequencies reflecting arousal (e.g., delta, alpha, beta).ConclusionsThe findings of this study suggest that only one night of mild sleep loss significantly increases sleepiness and, importantly, reduces vigilance. In addition, this sleep loss has a clear impact on the physiology of the brain in ways that reflect reduced arousal.SignificanceUnderstanding the neural correlates and cognitive processes associated with loss of sleep may lead to important advancements in identifying and preventing deleterious or potentially dangerous, sleep-related lapses in vigilance.     

EEG sleep and affective psychoses: I. Schizoaffective disorders.

The sleep electroencephalogram (EEG) was studied in 41 depressed inpatients. EEG sleep records were compared for two diagnostic subgroups; patients with psychotic depression (n = 29) or with schizoaffective disorders (n = 12). As was true in the previous pilot study, no major EEG sleep variables distinguished the patients with psychotic depression from those with schizoaffective disorders. These data are consistent with the theory that all psychotic depressive states may have certain common psychobiologic features such as shortened rapid eye movement (REM) sleep latency.     

Neonatal herpes simplex meningoencephalitis: EEG investigations and clinical correlates

We studied the sequential EEGs of 15 neonatal herpes simplex virus meningoencephalitis (NHSV-ME) patients and correlated them with corresponding clinical and laboratory findings. During days 1 to 4 of the illness, 8 had EEGs. All but 1 had abnormal tracings and 3 (38%) showed the multifocal periodic pattern (MPP). Three had an early abnormal EEG at a time when their cranial CT/ultrasound studies were normal. During days 5 to 11, 13 had EEGs: all were abnormal and 3 showed the MPP. After day 11, EEGs (available on 10) showed a very low voltage background in 9, and only 1 had normal EEG and development. During 1 year in which 1 patient with NHSV-ME was observed, we noted that 9/324 (2.8%) of neonates with other CNS conditions manifested the MPP. All, however, had CSF findings that distinguished them from herpes cases. We conclude that: (1) In patients with suspected NHSV-ME, EEG is a sensitive test that is superior to radiologic procedures in detecting early cerebral involvement. Most of the early EEGs show nonspecific background and paroxysmal abnormalities. (2) In the presence of inflammatory CSF, the MPP, an otherwise nonspecific finding, is highly suggestive of NHSV-ME. (3) Sequential EEGs may be important in the follow-up of neonates with NHSV-ME.