CLINICAL ELECTROENCEPHALOGRAPHY
@
1979.VOL.lO.NO 1
All Night Sleep Deprivation in Psychiatric Patients: Relation to Mood, EEG and Psychiatric Diagnosis Victor Milstein, Joyce G. Small, Patricia Sharpley and Sara Golay
Much recent interest in psychiatry has been expressed about apparent beneficial effects of all night sleep deprivation upon symptoms of depression and to a lesser extent schizophrenia. Numerous studies have been reported, most of them positive, of a transient or even prolonged improvement immediately following a single night of total or REM sleep deprivation l-'. However, blind control led observations are often lacking and it is not possible to know how much these changes were related to placebo effects, concomitant medication, patient expectations and/or observer bias8. In order to study these issues objectively, sleep deprivation was introduced as a routine EEG procedure for patients over the age of 40 in an acute psychiatric hospital. The procedure was justified to staff and patients alike as a relatively standard method of improving the quality of sleep EEG studies and enhancing paroxysmal abnormalities in an age group for whom sleep induction with sedatives is often not successful in our experience. However, our central, unstated interest was in observing the effects on mood of all night sleep deprivation in a population selected for a high incidence of depression and affective disorder. In addition, weevaluated theeffects of the procedure upon the EEG and examined psychiatric diagnosis and criteria for diagnosis in relationship to the EEG findings.
ings during waking, drowsiness, and sleep and during photic stimulation and hyperventilation. After explanation of the procedure and its purpose of facilitating the EEG study to be done the next day, physicians wroteorders for the patients to be kept awake. They were observed by ward personnel who monitored them continually throughout the night. The patients wore their day clothes, drank all the coffee they wanted, talked with staff and employed other strategies to remain awake the entire night. Some of the patients stated that they drowsed for brief periods, but such were too short to be noted by the staff. Eight to 12 hours beforethenight the patient was to remain awake, a variety of mood, perception and memory tests were administered. These included the Adjective Check List for Depressiong,the Zung Depression Scalelo, the Depression Check List", the Langner Scale of Depression12,the Kinesthetic Figural Aftereffects TestT3,the Wechsler Memory Sca1el4, and the Stanford Sleepiness Scale15. These were repeated the next day after the patient had been deprived of sleep for one night, and again approximately 7-10 days later. The clinical EEG was recorded during the afternoon following the night of sleep deprivation. The Feighner et a1.16 clinical research diagnostic criteria were completed for each patient on the basis of information contained in the patient's chart. This instrument provides a systematic. reliable assessment of a variety of
Subjects and Procedure: Over an interval of nearly a year all consenting patients over 40 years of age in whom there were no physical, psychiatric, or personal contraindications, were kept awake the third night of their admission to an acute inpatient facility which receives state-wide referrals of patients for intensive treatment, teaching, and research. Sixty-three patients were sleep deprived and later evaluated with EEG record-
Victor Milstein is Professor of Clinical Psychology (Psychiatry) and Psychophysiologist. Joyce G. Small is Professor of Psychiatry and Director of Research and Laboratories, Patricia Sharpley is Associate Professor of Psychiatry and Chief of Female Services, and Sara Golay is R . EEG. T. a i tne Larue D. Carter Memorial Hospital and Indiana University School of Medicine. Requests for reprints should be addressed to Victor Milstein. Ph.D , Larue D . Carter Memorial Hospital, 1315 West 10th Street, Indianapolis. Indiana 46202.
25 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
1979 VOL 10.NO 1
not demonstrate any changes over the times of testing. Likewise, the Zung Depression Scale and subtests of the Wechsler Memory Scale showed no significant differences with sleep deprivation. However, other measures of depressed mood such as the Adjective Check List, the Langner Scale and the Depression Check List all demonstrated the same trend and were improved the day after sleep deprivation. The Memory Quotient derived from the Wechsler Memory Scale was also significantly improved. The scores on the perception, mood and memory evaluations were correlated with items from the Feighner research diagnostic criteria. The Adjective Check List, Langner Depression Scale and Depression Check List tended to correlate with signs and symptoms of anxiety and neurosis, while the perception and memory test scores were associated with age of onset of psychiatric illness, presence of hyperactivity, intelligible speech, and degree of impairment on admission. Comparisons between subjects and controls are shown in Table 1 . Note that 72% of the sleep deprived patients had a complete and successful sleep recording in the EEG laboratory. Separating the groups into those who slept in the EEG laboratory, whether following one night sleep deprivation or secobarbital sedation, revealed that the sleep deprivation procedure was almost completely successful for the males, 14 (88%) of whom slept, and less so for the females of whom 25 (67%) slept. There were no statistically significant differences between the sleep deprived patients and their controls in terms of the overall EEG diagnosis. However, there were fewer borderline and minimally abnormal judgments of the EEGs of the sleep deprived patients compared to the controls (whether they slept or not). Of the 26 specific EEG features we examined, only one showed statistically significant differences between the sleep deprived patients and their matched controls. This was the incidence of intermittent EEG variants such as positive spikes, small sharp spikes and/or 6/sec spike-wave paroxysms which significantly separated the two groups with thesleep deprived patients having a greater incidence, Results However, as indicated in Table 1, this increase The majority of the ratings of mood, percep- was provided by patients who did not sleep. tion and memory showed no change before Hence, these features appeared in the waking and the day after sleep deprivation. Specifically states after 24 hours of sleep deprivation. No /3 the Kinesthetic Figural Aftereffects Test did mitten patterns18were identified in subjects or
criteria for psychiatric diagnosis. Each manifestation or symptom was rated as present or absent and the formal diagnosis was established from the array of items. TheTsuang and Winokur” descriptions of paranoid and hebephrenic subtypes were also scored in all patients. The patients ranged in age from 40 to 78 years. Although not all could be successfully evaluated to provide scores on the tests of mood, perception and memory before and after sleep deprivation, all of the 63 subjects had EEG studies occupying more than one hour of recording time. Sedation was not used in the sleep deprived patients. To provide a basis for comparison of the results from the sleep deprived patients, they were matched with patients of the same sex and age (within 3 years) who had received EEGs prior to the initiation of the sleep deprivation study. These patients had been treated in our usual fashion in attempting to record a waking and sleeping EEG. That is, if natural sleep was not forthcoming, sodium secobarbital 100-200mg was administered. Less than half (49%) of these agehex matched patients were found to have slept, a proportion significantly below that of the sleep-deprived subjects (72Y0).We therefore selected as controls, patients who were matched for sex and age but who also had the same sleep experience in the EEG laboratory. That is, if the sleep deprived patient slept, his matched control also slept; if not, then the control was required not to have had a successful sleep recording. Sixty sleep-deprived patients could be so matched. Of this number of matched controls, only one patient slept spontaneously in the EEG laboratory. All of the others received secobarbital to aid in producing sleep. All EEGs were interpreted with only knowledge of the patient’s age available until the initial impression was dictated. Records from patients in the study were not separated from others recorded in the laboratory at the same time. The waking, sleep and activation responses each were described in detail. From these descriptions, the EEG data were entered onto code sheets suitable for computer analysis.
26 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
1979 VOL 10.NO 1
TABLE 1 COMPARISON OF SLEEP DEPRIVED PATIENTS AND MATCHED CONTROLS All Patients Sleep Deprived Controls N Mean Age (years) Sex Ratio (ma1es:females) EEG: TONormal O/o Borderline and Minimal Abnormal O/O Moderate and Severely Abnormal Incidence of Positive Spikes, Small Sharp Spikes or 6/sec. Spike Waves (%) None or Rare
53 50.7
Occasional or Frequent Deviant Response to Photic Stimulation (%)
16:37 51 34 15
16:37 42 49 9
34
60
66 30
40 28
Patients Who Slept Patients Who Didn't Sleep Sleep Sleep Deprived Controls Deprived Controls 39 N 50.0 Mean Age (years) 14:25 14:25 Sex Ratio (ma1es:females) 44 44 EEG: W Normal O/o Borderline and Minimal Abnormal 41 49 O h Moderate and Severely Abnormal 15 8 Incidence of Positive Spikes, Small Sharp Spikes or 6/sec. Spike Waves ( O h ) None or Rare 26 54
Occasional or Frequent Deviant Response to Photic Stimulation (YO) ' X 2 probability
64 26
46 26
14 52.1 2:12 71 14 14
2:12 36 50 14
29
78
71 21
22 14
02
controls. Based on the Feighner clinical research diagnostic criteria, 49% of the sleep deprived subjects received a diagnosis of primary or secondary affective disorder, either manic or depressed, while 46% of the control patients were so diagnosed. The comparable figures for the diagnosis of schizophrenia were 22% and 16%. The remaining 29 or 28% of the sleep-deprived and control groups were comprised of patients with anxiety neuroses, organic brain syndromes, personality disorders, and alcoholism.
We then attempted to discover whether there were any relationships among the EEG features that we had examined and the individual diagnostic criteria of the patients who were sleep-deprived. Table 2 indicates some of the statistically reliable associations between EEG variables and clinical ratings. An abnormal goneral EEG diagnosis was positively related to manifestations of irritability and negatively to diagnosis of both schizophrenia and primary affective disorders. Since many of the EEG features rated were intercorrelated, they are shown to relate to the 27
Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
e1979VOL 10.NO 1
TABLE 2 Direction' General EEG Impression
+ Irritable
+ Irritable
+ Waking EEG Abnormality
Symptom
Chronic schizophrenic illness with 6 months of symptoms without return to premorbid level of psychosocial adjustment. Absence of period of depression of manic symptoms sufficient for diagnosis of primary affective disorder.
+ Irritable
+ +
Loss of interest in usual activities or decrease i n sexual drive Poor premorbid social adjustment or work history. - Diagnosis of primary affective disorder, definite or probable, depression or mania.
Drowsy EEG Abnormality
+ Complaints of
Sleep EEG Abnormality
+ Flat affect.
Deviant or Abnormal Photic Response
or actual diminished ability to concentrate (slow thinking or mixed-up thoughts). + Poor premorbid social adjustment or work history. + Unmarried or unemployed. + Family history of schizophrenia. + Flat affect.
+ Recurrent thoughts of death or suicide - wishing to be dead. + A psychiatric illness lasting at least 1 month with no preexisting psychiatric conditions.
+ Unmarried or unemployed. Abnormal HV Response
+ Age of onset of psychiatric condition after 25 years
Abnormal Frequencies + Poor appetite or weight loss. Theta + Agitation or retardation.
*
Delta
+ Loss of interest in usual activities or decrease in sexual drive
Spike
- Diagnosis of primary affective disorder, definite or probable, depression or mania.
+ means that a more abnormal EEG rating is associated with the clinical manifestation; - means a less abnormal EEG is associated with the item.
same clinical feature. EEG abnormalities during waking were positively associated with irritability, loss of interest in usual activities or a decrease in sexual drive and poor premorbid social adjustment or work history, and to some diagnosis other than primary affective disorder. An abnormal EEG during drowsiness was significantly related to diminished ability
to concentrate and poor premorbid social adjustment or work history. Tsuang and Winokurt7 items of flat affect, family history of schizophrenia and being unmarried or unemployed also related to EEG abnormalities during drowsiness. An abnormal sleep record was associated only with the presence of flat affect. Abnormal responses to hyperventilation were
28 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
significantly related only to onset of illness after age twenty-five, while deviant responses to photic stimulation such as photoconvulsive or photomyoclonic responses were associated with recurrent thoughts of death or suicide, illness of more than one month's duration without pre-existing psychiatric condition, and unmarried or unemployed status. EEG frequency abnormalities were associated with several clinical signs: theta with poor appetite or weight loss and agitation or retardation; delta with loss of interest in usual activities or decrease in sexual drive; and spikes with a diagnosis other than primary affective disorder. No significant associations with beta or alpha band abnormalities or sharp waves were identified. Interestingly, the regional EEG abnormalities, whether generalized or localized, were not significantly associated with the clinical data.
Discussion and Conclusion This objective, mostly blind study has yielded at best negative or equivocal data. There were no consistent changes in mood the day after sleep deprivation. The Kinesthetic Figural Aftereffects Test has been reported to be associated with visual evoked potential augmenting and reducing which distinguishes among depressed p a t i e n t ~ l ~ , ~ ~ , and is related to chronic insomniaz3,but scores did
1979VOL 10.NO 1
not change after one night of sleep deprivation. However, those self rating measures which did change were all in the direction of improvement. The more consistent improvement after a week or more of hospital treatment was not as apt to be related to the deprivation procedure as much as to other therapeutic interventions. However, the results of this study demonstrate the efficacy of sleep deprivation in obtaining sleep EEG studies in older psychiatric patients. One night of sleep deprivation was much superior for induction of sleep than barbiturate sedation. Nearly three-quarters of the sleep deprived patients went to sleep as compared with 50% of a group of matched control patients given barbiturates. Also, the sleep deprived subjects demonstrated significantly more intermittent EEG deviations such as positive spikes, small sharp spikes, and Wsec spike-waves. The incidence of the variants demonstrated by our greater than 40 year old sleep-deprived patients was much higher than that obtained by Gibbs and NovickZ4who examined 1000 psychiatric patients ranging in age down to 20 years. Thus, we concluded that one night sleep deprivation in older psychiatric patients was not shown to produce significant therapeutic effects in the tests we employed. However, sleep deprivation did appear to be a useful procedure when a sleep EEG is considered important in such patients.
REFERENCES PLUG, B., and TOLLE, R., Disturbance of the 24hour rhythm in endogenous depression and the treatment of endogenous depression by sleep deprivation, lnf. Pharmacopysychiaf., 6:187-196, 1971. de BARROS-FERREIRA, M., GOLDSTEINAS, L., and LAIRY. G.C., REM sleep deprivation in chronic schizophrenics: effects on the dynamics of fast sleep, Electroenceph. clin. Neurophys~ol.,34~561-569,1973.
5. POST, R.M., KOTIN, J., and GOODWIN, F.K., Effects of sleep deprivation on mood and central amine metabolism in depressed patients, Arch. Gen. Psychiaf., 33:627-632, 1976. 6. PFLUG. B... The effect of sleep deprivation on depressed patients, Acta Psychiat. Scand., 53: 148-158, 1976, 7. LOOSEN, P.T., MERKEL,V..andAMELUNG,V., Combined sleep deprivation and clomipramine in primary depression, Lancet, 2:156-157, 1976.
BHANJI. S., and ROY, G.A., The treatment of psychotic depression by sleep deprivation: a replication study, J , Psychiat,, 127:222-226, 1975. VAN DEN BURG, w,, and VAN DEN HOOFDAKKER. R.H., Total sleep deprivation on endogenous depression, Arch. Gen. Psychiaf., 32:1121-1125, 1975.
8. KING, D., Pathological and therapeutic consew e n c e s of sleep loss: a review. Dis. Nerv. SYS., 281873479, 1977. 9. LUBIN, B.. Adjectivechecklist for measurement of depression, Arch. Gen. Psychiaf.. 12:57-62, 1965. 10. ZUNG, W.W.K., A self-rating depression scale, Arch, Gen. Psychiaf., 1263-70, 1965.
29 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
1979 VOL 10,NO 1
CLINICAL ELECTROENCEPHALOGRAPHY
1 1 . VOGEL, W., Depression check list, Worcester State Hospital, Mimeographed Version, 1972. 12. SHADER, R.I.. EBERT. M.H.. and HARMATZ, J.S.. Langner's psychiatric impairment scale: a short screening device, Amer. J. Psychiat.. 128: 596-601,1971, 13. PETRIE. A,. lndividuality in pain and suffering, Chicago, Univ. of Chicago Press, 1967. 14. WECHSLER. D.. A standardized scale for clinical use, J. Psycho/., 19:87-95,1945.
19. BUCHSBAUM, M.. GOODWIN, F., MURPHY, D.. and BORGE. G., AER in affective disorders, Amer. J. Psychiat., 128:19-25,1971. 20. BUCHSBAUM. M.. LANDAU. S., MURPHY, D., and GOODWIN. F.. Average evoked response in bipolar and unipolar affective disorders: relation to sex, age of onset, and monoamine oxidase, Biol. Psychiat.. 7:199-212.1973.
2l. LANDAU, S.G., BUCHSBAUM, M.S.. CARPENTER, W., STRAUSS, J . , and SOCKS, M., Schizophrenia and stimulus intensity control, Arch. Gen. Psychiat.. 32:1239-1245. 1975.
15. HODDES. E.. ZARCONE. V., SMYTHE. H., PHILLIPS, R., and DEMENT, W.C.. Quantification of sleepiness: a new approach, psycho1973. physiol., 10:431-436,
22. BUCHSBAUM, M., Average evoked response augmentingheducing in schizophrenia and affective disorders, In D.X. Freedman (Ed.) Biology of the Major psychosis, Res, pub/, Assoc. Nerv. Ment. Dis., Vol. 54,Raven Press, New York.
16. FEIGHNER, J.P.1 ROBBINS8 E., GUZE, S.B., WOODRUFF, R.A., WINOKUR. G., and MUNOY. R.. Diagnostic criteria for use in psychiatric research, Arch. Gen. Psychiat., 26:57-63.1972.
17. TSUANG, M.T., and WINOKUR, G.. Criteria for
1975, 23. COURSEY, R.D., Personality measures and evoked responses in chronic insomniacs,
subtyping schizophrenia, Arch. Gen. Psychiat.,
18. GIBBS, F.A., and GIBBS, E.L., The mitten pat-
J,
Abn, Psychol,,
84:239-249,1975.
21 143-47, 1974.
24. GIBBS, F.A., and NOVICK, R.G., Electroencephalographic findings among adult patients in a private psychiatric hospital, Clin. Electroenceph., 8~79-88, 1977.
tern: an electroencephalographic abnormality correlating with psychosis, J. Neuropsychiat.,
5:6-13.1963.
30 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
@
1979.VOL.lO.NO 1
All Night Sleep Deprivation in Psychiatric Patients: Relation to Mood, EEG and Psychiatric Diagnosis Victor Milstein, Joyce G. Small, Patricia Sharpley and Sara Golay
Much recent interest in psychiatry has been expressed about apparent beneficial effects of all night sleep deprivation upon symptoms of depression and to a lesser extent schizophrenia. Numerous studies have been reported, most of them positive, of a transient or even prolonged improvement immediately following a single night of total or REM sleep deprivation l-'. However, blind control led observations are often lacking and it is not possible to know how much these changes were related to placebo effects, concomitant medication, patient expectations and/or observer bias8. In order to study these issues objectively, sleep deprivation was introduced as a routine EEG procedure for patients over the age of 40 in an acute psychiatric hospital. The procedure was justified to staff and patients alike as a relatively standard method of improving the quality of sleep EEG studies and enhancing paroxysmal abnormalities in an age group for whom sleep induction with sedatives is often not successful in our experience. However, our central, unstated interest was in observing the effects on mood of all night sleep deprivation in a population selected for a high incidence of depression and affective disorder. In addition, weevaluated theeffects of the procedure upon the EEG and examined psychiatric diagnosis and criteria for diagnosis in relationship to the EEG findings.
ings during waking, drowsiness, and sleep and during photic stimulation and hyperventilation. After explanation of the procedure and its purpose of facilitating the EEG study to be done the next day, physicians wroteorders for the patients to be kept awake. They were observed by ward personnel who monitored them continually throughout the night. The patients wore their day clothes, drank all the coffee they wanted, talked with staff and employed other strategies to remain awake the entire night. Some of the patients stated that they drowsed for brief periods, but such were too short to be noted by the staff. Eight to 12 hours beforethenight the patient was to remain awake, a variety of mood, perception and memory tests were administered. These included the Adjective Check List for Depressiong,the Zung Depression Scalelo, the Depression Check List", the Langner Scale of Depression12,the Kinesthetic Figural Aftereffects TestT3,the Wechsler Memory Sca1el4, and the Stanford Sleepiness Scale15. These were repeated the next day after the patient had been deprived of sleep for one night, and again approximately 7-10 days later. The clinical EEG was recorded during the afternoon following the night of sleep deprivation. The Feighner et a1.16 clinical research diagnostic criteria were completed for each patient on the basis of information contained in the patient's chart. This instrument provides a systematic. reliable assessment of a variety of
Subjects and Procedure: Over an interval of nearly a year all consenting patients over 40 years of age in whom there were no physical, psychiatric, or personal contraindications, were kept awake the third night of their admission to an acute inpatient facility which receives state-wide referrals of patients for intensive treatment, teaching, and research. Sixty-three patients were sleep deprived and later evaluated with EEG record-
Victor Milstein is Professor of Clinical Psychology (Psychiatry) and Psychophysiologist. Joyce G. Small is Professor of Psychiatry and Director of Research and Laboratories, Patricia Sharpley is Associate Professor of Psychiatry and Chief of Female Services, and Sara Golay is R . EEG. T. a i tne Larue D. Carter Memorial Hospital and Indiana University School of Medicine. Requests for reprints should be addressed to Victor Milstein. Ph.D , Larue D . Carter Memorial Hospital, 1315 West 10th Street, Indianapolis. Indiana 46202.
25 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
1979 VOL 10.NO 1
not demonstrate any changes over the times of testing. Likewise, the Zung Depression Scale and subtests of the Wechsler Memory Scale showed no significant differences with sleep deprivation. However, other measures of depressed mood such as the Adjective Check List, the Langner Scale and the Depression Check List all demonstrated the same trend and were improved the day after sleep deprivation. The Memory Quotient derived from the Wechsler Memory Scale was also significantly improved. The scores on the perception, mood and memory evaluations were correlated with items from the Feighner research diagnostic criteria. The Adjective Check List, Langner Depression Scale and Depression Check List tended to correlate with signs and symptoms of anxiety and neurosis, while the perception and memory test scores were associated with age of onset of psychiatric illness, presence of hyperactivity, intelligible speech, and degree of impairment on admission. Comparisons between subjects and controls are shown in Table 1 . Note that 72% of the sleep deprived patients had a complete and successful sleep recording in the EEG laboratory. Separating the groups into those who slept in the EEG laboratory, whether following one night sleep deprivation or secobarbital sedation, revealed that the sleep deprivation procedure was almost completely successful for the males, 14 (88%) of whom slept, and less so for the females of whom 25 (67%) slept. There were no statistically significant differences between the sleep deprived patients and their controls in terms of the overall EEG diagnosis. However, there were fewer borderline and minimally abnormal judgments of the EEGs of the sleep deprived patients compared to the controls (whether they slept or not). Of the 26 specific EEG features we examined, only one showed statistically significant differences between the sleep deprived patients and their matched controls. This was the incidence of intermittent EEG variants such as positive spikes, small sharp spikes and/or 6/sec spike-wave paroxysms which significantly separated the two groups with thesleep deprived patients having a greater incidence, Results However, as indicated in Table 1, this increase The majority of the ratings of mood, percep- was provided by patients who did not sleep. tion and memory showed no change before Hence, these features appeared in the waking and the day after sleep deprivation. Specifically states after 24 hours of sleep deprivation. No /3 the Kinesthetic Figural Aftereffects Test did mitten patterns18were identified in subjects or
criteria for psychiatric diagnosis. Each manifestation or symptom was rated as present or absent and the formal diagnosis was established from the array of items. TheTsuang and Winokur” descriptions of paranoid and hebephrenic subtypes were also scored in all patients. The patients ranged in age from 40 to 78 years. Although not all could be successfully evaluated to provide scores on the tests of mood, perception and memory before and after sleep deprivation, all of the 63 subjects had EEG studies occupying more than one hour of recording time. Sedation was not used in the sleep deprived patients. To provide a basis for comparison of the results from the sleep deprived patients, they were matched with patients of the same sex and age (within 3 years) who had received EEGs prior to the initiation of the sleep deprivation study. These patients had been treated in our usual fashion in attempting to record a waking and sleeping EEG. That is, if natural sleep was not forthcoming, sodium secobarbital 100-200mg was administered. Less than half (49%) of these agehex matched patients were found to have slept, a proportion significantly below that of the sleep-deprived subjects (72Y0).We therefore selected as controls, patients who were matched for sex and age but who also had the same sleep experience in the EEG laboratory. That is, if the sleep deprived patient slept, his matched control also slept; if not, then the control was required not to have had a successful sleep recording. Sixty sleep-deprived patients could be so matched. Of this number of matched controls, only one patient slept spontaneously in the EEG laboratory. All of the others received secobarbital to aid in producing sleep. All EEGs were interpreted with only knowledge of the patient’s age available until the initial impression was dictated. Records from patients in the study were not separated from others recorded in the laboratory at the same time. The waking, sleep and activation responses each were described in detail. From these descriptions, the EEG data were entered onto code sheets suitable for computer analysis.
26 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
1979 VOL 10.NO 1
TABLE 1 COMPARISON OF SLEEP DEPRIVED PATIENTS AND MATCHED CONTROLS All Patients Sleep Deprived Controls N Mean Age (years) Sex Ratio (ma1es:females) EEG: TONormal O/o Borderline and Minimal Abnormal O/O Moderate and Severely Abnormal Incidence of Positive Spikes, Small Sharp Spikes or 6/sec. Spike Waves (%) None or Rare
53 50.7
Occasional or Frequent Deviant Response to Photic Stimulation (%)
16:37 51 34 15
16:37 42 49 9
34
60
66 30
40 28
Patients Who Slept Patients Who Didn't Sleep Sleep Sleep Deprived Controls Deprived Controls 39 N 50.0 Mean Age (years) 14:25 14:25 Sex Ratio (ma1es:females) 44 44 EEG: W Normal O/o Borderline and Minimal Abnormal 41 49 O h Moderate and Severely Abnormal 15 8 Incidence of Positive Spikes, Small Sharp Spikes or 6/sec. Spike Waves ( O h ) None or Rare 26 54
Occasional or Frequent Deviant Response to Photic Stimulation (YO) ' X 2 probability
64 26
46 26
14 52.1 2:12 71 14 14
2:12 36 50 14
29
78
71 21
22 14
02
controls. Based on the Feighner clinical research diagnostic criteria, 49% of the sleep deprived subjects received a diagnosis of primary or secondary affective disorder, either manic or depressed, while 46% of the control patients were so diagnosed. The comparable figures for the diagnosis of schizophrenia were 22% and 16%. The remaining 29 or 28% of the sleep-deprived and control groups were comprised of patients with anxiety neuroses, organic brain syndromes, personality disorders, and alcoholism.
We then attempted to discover whether there were any relationships among the EEG features that we had examined and the individual diagnostic criteria of the patients who were sleep-deprived. Table 2 indicates some of the statistically reliable associations between EEG variables and clinical ratings. An abnormal goneral EEG diagnosis was positively related to manifestations of irritability and negatively to diagnosis of both schizophrenia and primary affective disorders. Since many of the EEG features rated were intercorrelated, they are shown to relate to the 27
Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
e1979VOL 10.NO 1
TABLE 2 Direction' General EEG Impression
+ Irritable
+ Irritable
+ Waking EEG Abnormality
Symptom
Chronic schizophrenic illness with 6 months of symptoms without return to premorbid level of psychosocial adjustment. Absence of period of depression of manic symptoms sufficient for diagnosis of primary affective disorder.
+ Irritable
+ +
Loss of interest in usual activities or decrease i n sexual drive Poor premorbid social adjustment or work history. - Diagnosis of primary affective disorder, definite or probable, depression or mania.
Drowsy EEG Abnormality
+ Complaints of
Sleep EEG Abnormality
+ Flat affect.
Deviant or Abnormal Photic Response
or actual diminished ability to concentrate (slow thinking or mixed-up thoughts). + Poor premorbid social adjustment or work history. + Unmarried or unemployed. + Family history of schizophrenia. + Flat affect.
+ Recurrent thoughts of death or suicide - wishing to be dead. + A psychiatric illness lasting at least 1 month with no preexisting psychiatric conditions.
+ Unmarried or unemployed. Abnormal HV Response
+ Age of onset of psychiatric condition after 25 years
Abnormal Frequencies + Poor appetite or weight loss. Theta + Agitation or retardation.
*
Delta
+ Loss of interest in usual activities or decrease in sexual drive
Spike
- Diagnosis of primary affective disorder, definite or probable, depression or mania.
+ means that a more abnormal EEG rating is associated with the clinical manifestation; - means a less abnormal EEG is associated with the item.
same clinical feature. EEG abnormalities during waking were positively associated with irritability, loss of interest in usual activities or a decrease in sexual drive and poor premorbid social adjustment or work history, and to some diagnosis other than primary affective disorder. An abnormal EEG during drowsiness was significantly related to diminished ability
to concentrate and poor premorbid social adjustment or work history. Tsuang and Winokurt7 items of flat affect, family history of schizophrenia and being unmarried or unemployed also related to EEG abnormalities during drowsiness. An abnormal sleep record was associated only with the presence of flat affect. Abnormal responses to hyperventilation were
28 Downloaded from eeg.sagepub.com at City University Library on April 2, 2016
CLINICAL ELECTROENCEPHALOGRAPHY
significantly related only to onset of illness after age twenty-five, while deviant responses to photic stimulation such as photoconvulsive or photomyoclonic responses were associated with recurrent thoughts of death or suicide, illness of more than one month's duration without pre-existing psychiatric condition, and unmarried or unemployed status. EEG frequency abnormalities were associated with several clinical signs: theta with poor appetite or weight loss and agitation or retardation; delta with loss of interest in usual activities or decrease in sexual drive; and spikes with a diagnosis other than primary affective disorder. No significant associations with beta or alpha band abnormalities or sharp waves were identified. Interestingly, the regional EEG abnormalities, whether generalized or localized, were not significantly associated with the clinical data.
Discussion and Conclusion This objective, mostly blind study has yielded at best negative or equivocal data. There were no consistent changes in mood the day after sleep deprivation. The Kinesthetic Figural Aftereffects Test has been reported to be associated with visual evoked potential augmenting and reducing which distinguishes among depressed p a t i e n t ~ l ~ , ~ ~ , and is related to chronic insomniaz3,but scores did
1979VOL 10.NO 1
not change after one night of sleep deprivation. However, those self rating measures which did change were all in the direction of improvement. The more consistent improvement after a week or more of hospital treatment was not as apt to be related to the deprivation procedure as much as to other therapeutic interventions. However, the results of this study demonstrate the efficacy of sleep deprivation in obtaining sleep EEG studies in older psychiatric patients. One night of sleep deprivation was much superior for induction of sleep than barbiturate sedation. Nearly three-quarters of the sleep deprived patients went to sleep as compared with 50% of a group of matched control patients given barbiturates. Also, the sleep deprived subjects demonstrated significantly more intermittent EEG deviations such as positive spikes, small sharp spikes, and Wsec spike-waves. The incidence of the variants demonstrated by our greater than 40 year old sleep-deprived patients was much higher than that obtained by Gibbs and NovickZ4who examined 1000 psychiatric patients ranging in age down to 20 years. Thus, we concluded that one night sleep deprivation in older psychiatric patients was not shown to produce significant therapeutic effects in the tests we employed. However, sleep deprivation did appear to be a useful procedure when a sleep EEG is considered important in such patients.
REFERENCES PLUG, B., and TOLLE, R., Disturbance of the 24hour rhythm in endogenous depression and the treatment of endogenous depression by sleep deprivation, lnf. Pharmacopysychiaf., 6:187-196, 1971. de BARROS-FERREIRA, M., GOLDSTEINAS, L., and LAIRY. G.C., REM sleep deprivation in chronic schizophrenics: effects on the dynamics of fast sleep, Electroenceph. clin. Neurophys~ol.,34~561-569,1973.
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