Maria Teresa Ratti

Poor sleep in adolescents: A study of 869 17-year-old Italian secondary school students

Subjective sleep quality and its related factors were investigated in 869 (530 F, 339 M) 17‐year‐old adolescents, who were selected from the pupils of state‐run secondary schools in the city of Pavia in the north west of Italy. The study was conducted cross sectionally, and it consisted of a questionnaire based survey. One hundred and forty‐two subjects (16.5% of the whole sample, 19% of the females and 11.7% of the males) met the criteria chosen for definition as poor sleepers (namely, a complaint of «non restorative nocturnal sleep», «often» or «always» over the previous 12 mo). A significant association was found between chronic poor sleep and (1) gender (female) (2) emotional factors, such as worries, anxiety and depression (3) poor sleep hygiene (4) arousal related parasomnia. Only 4% of poor sleepers took sleep promoting drugs (including benzodiazepines, homeopathic products and other medications), generally without seeking medical advice.

Patients with psychogenic nonepileptic seizures, alone or epilepsy-associated, share a psychological profile distinct from that of epilepsy patients

Abstract. The aim of this study was twofold: 1 – to identify a psychological profile of patients with psychogenic nonepileptic seizures (PNESs) that is possibly distinct from that of subjects affected by epileptic seizures (ESs) alone; 2 – to detect the possible differences between the clinical features and psychological profile of patients affected by PNESs alone and those of subjects in whom PNESs are associated with epileptic seizures (ES/PNES patients).We assessed the psychological profiles of 2 different groups of subjects. The first group was of 38 patients who had all developed PNESs after epileptic seizures (ES\PNES, group 1). The second group was of 31 patients with PNESs alone (PNES, group 2). We compared the psychological findings of each of these 2 groups with those of 2 control groups, composed of patients who matched groups 1 and 2 for sex, age, and educational level, but who were affected only by ESs (groups 1C and 2C). Finally, we considered possible differences between the ictal symptoms and signs of PNESs occurring in ES/PNES and in PNES patients.Both the ES/PNES group and the PNES group revealed higher percentages of Somatoform Disorders and Cluster B Personality Disorders (DSM-III-R diagnoses) than the ES patients in the control groups. The scores obtained on the Psychophysiological Distress Scale of the Cognitive Behavioural Assessment Battery (CBA) followed the same pattern.Among PNES ictal phenomena, autonomic symptoms and signs were significantly more frequent in the PNES than in the ES/PNES group. The occurrence of PNESs mimicking generalised tonic-clonic ESs (GTC-PNESs) was significantly associated with a low academic level.The results of this study suggest that the patients with PNESs alone and those affected by PNESs and ESs share the same psychological profile, which is different from that of patients with ESs alone. However, some differences between ES/PNES and PNES patients were found in the clinical semiology of their PNESs. Our findings could have implications for the diagnosis and for the treatment of patients with PNESs.

Daytime sleepiness in epilepsy patients: evaluation by means of the Epworth sleepiness scale

Sirs: Epilepsy patients on antiepileptic drugs (AEDs) are known to complain frequently of drowsiness [1]. In clinical practice the evaluation of daytime sleepiness in epilepsy patients is based mainly on the patient’s report at the clinical interview. Most clinicians tend to shortly attribute drowsiness in epilepsy patients to AEDs. Recently Vaughan et al. [6] and Malow et al. [5] used the Epworth Sleepiness Scale (ESS) [3] to evaluate daytime sleepiness in epilepsy patients, with the following principal findings: (a) the degree of daytime sleepiness of epilepsy patients did not differ significantly from that of control subjects affected with other neurological disorders, (b) coexisting symptoms suggestive of obstructive sleep apnea (OSA) and/or restless legs syndrome (RLS) are stronger predictors of subjective daytime sleepiness than AEDs or type and frequency of epileptic seizures. We prospectively evaluated sleepiness by means of the ESS in a series of Italian epilepsy patients followed over a 12-month period. The series consisted of 244 patients (117 men, 127 women; mean age 33.5±11.2 years; mean body mass index 23.7±3.7) whose biometric and clinical details are presented in Table 1. Controls consisted of 205 healthy subjects, comparable in age, sex, and biometric parameters (98 men, 107 women; mean age 31.8±13.4 years; mean body mass index 21.7±3.3). Each subject completed both an Italian version of the ESS [2] and a multiple-choice questionnaire of 112 items concerning sleep habits, quantity, quality of nocturnal sleep, and sleep disorders. Raw scores of ESS in epilepsy and control groups are presented in Table 2. Mean global raw ESS scores in epilepsy and control groups (5.6±3.4 and 5.7±3.6, respectively) did not differ significantly using one-way analysis of variance. In 27 epilepsy patients (11%) and 20 controls (10%) the global ESS score exceeded the upper limit of the normal range of the ESS (i. e., their score was > 10; not significantly different by χ2 test). Analysis of variance or calculation of Pearson’s correlation coefficient, depending on the categorial or continuous nature of the variables, was carried out to examine the possible effects of background and epilepsy variables on ESS score in the epilepsy patients. The following variables were significantly correlated to the global ESS score: loud/habitual snoring and/or observed apneas during nocturnal sleep (F=6.1, df=1 P< 0.01) and recurrence of seizures during the past year LETTER TO THE EDITORS

A multiparametric investigation of daytime sleepiness and psychomotor functions in epileptic patients treated with phenobarbital and sodium valproate: a comparative controlled study

Subjective and objective measures of daytime sleepiness and psychomotor function were determined in normal control subjects and in epileptic patients on chronic monotherapy with phenobarbital or valproate (n = 10 in each group). All patients had primary generalized epilepsy with a normal resting EEG and were seizure-free for at least 1 year. After nocturnal polysomnographic recording, each subject was evaluated at 2 h intervals between 10:00 and 16:00 h by using multiple sleep latency tests (MSLT), a visual analogue rating scale for alertness (VARS), an anxiety scale (STAI-X1) and a battery of psychomotor tests. Nocturnal sleep parameters before daytime assessment were comparable in the 3 groups. At MSLT, patients on phenobarbital showed a shorter mean sleep latency (9.0 +/- 1.7 min) compared with the valproate group (12.5 +/- 1.3 min) and controls (12.9 +/- 1.2 min), though within-group variability was considerable. Compared with controls, patients on phenobarbital showed longer motor movement times, impaired attention (cancellation test, CT), reduced processing speed (digit-symbol substitution, DSS) and a trend towards lower critical flicker fusion threshold. Patients on valproate showed some impairment in attention and a trend towards longer motor movement time. In patients, no correlation was found between assessed parameters and serum drug concentrations, which were 19.3 +/- 1.7 micrograms/ml for phenobarbital and 85.7 +/- 4.7 micrograms/ml for valproic acid.

Cognitive impairment and cerebral atrophy in “heavy drinkers”

1. Aim of the work was to verify the following three hypotheses in alcoholics: a) right hemisphere; b) diffuse brain deficit; c) anterior brain deficit, by means of a neuropsychological and a neuroradiological assessment. 2. 15 alcoholic right-hand male subjects and 15 matched controls were enrolled in the study. 3. Specifically designed neuropsychological testing was performed to investigate logical abilities, selective attention and memory. 4. Neurological investigation was performed by a standard CT scan to assess the degree and localization of brain damage. 5. Alcoholics performed worse than controls on some neuropsychological tests, i.e. Attention Matrices Test, Verbal Judgement Test, Forward Digit Span, Story Recall and Remote Memory Test. The analysis of variance adjusted by the attentional score showed no significant differences between alcoholics and controls. 6. Neuroradiological data showed a preeminent and a more frequent atrophy of the frontal region. 7. No correlations emerged between neuropsychological and neuroradiological data. 8. In conclusion, the hypothesis of anterior brain deficit seems to be confirmed by our study.

Electrophysiological and immunogenetic findings in recurrent monosymptomatic‐type hypersomnia: a study of two unrelated Italian cases

MSLT and immunogenetic findings in two unrelated Italian subjects with recurrent monosymptomatic hypersomnia are reported. In both patients MSLT documented a markedly increased daytime sleep propensity during the attacks without augmented REM sleep pressure. Both patients share the same HLA haplotype (HLA‐DR1, DQ1) which has been found in Kleine‐Levin syndrome. This makes these subtypes of recurrent hypersomnia indistinguishable one from the other, under the immunogenetic profile, but permits differentiation from narcolepsy which is HLA‐DR2, DQ1 closely linked.

Sleepiness in obstructive sleep apnea syndrome and simple snoring evaluated by the Epworth Sleepiness Scale

Sleep medicine literature is increasingly featuring data Fifty-four normal weight subjects matched to OSA patients concerning the Epworth Sleepiness Scale (ESS) as a measure for age and sex served as controls. These subjects were recruited of daytime sleepiness in clinical practice. We read with interest among friends of out-patients referring to our Institute of the paper by Olson et al. (1988) which, in contrast to Johns Neurology. They were healthy, drug-free nonsnorers. The (1993), finds that overall ESS score does not differ significantly control subjects did not have polysomnography. However they between obstructive sleep apnea syndrome (OSAS), snoring, all had a clinical and questionnaire based evaluation (Sleep and upper airways resistance syndrome in groups of patients. Disorders Questionnaire I of Douglass et al. 1994) aimed at Furthermore, Olson and colleagues failed to document any ruling out the existence of sleep disorders, namely OSA. Each significant relationship between ESS score and polygraphic of these subjects entered the study and provided the ESS data indexes of OSAS severity. They partly attribute the only if the subject’s raw score at subitems sleep-apnoea scale discrepancies between their findings and those of Johns to of SDQI fell in the normal range of the scale. differences in the pathways of referral of the patients, and in The mean global ESS score in OSAS patients was 11.7 (SD time and mode of scale completion. 4.6; range 4–20), in primary snoring patients 5.8 (SD 2.4; range Here we report ESS data collected from an Italian case series 2–11), and in healthy controls 4.4 (SD 2.8; range 0–11). The of OSAS, in which the snoring patient pathway of referral was mean overall ESS score is significantly higher in OSAS than similar to that in Olson’s experience, while time and mode of in simple snoring patients (P < 0.001 at one way  with completion of the scale were analogous to those adopted by post hoc Scheffè test). Johns. Overall ESS scores for the 54 OSAS patients were correlated The case series consisted of consecutive, non fee-paying adult with the RDI, nocturnal HbSaO2 nadir, age, and BMI by patients, referring to the Sleep Medicine Centre of the Institute means of the rho Spearman test (Table 1). of Neurology ‘C. Mondino’ between September 1997 and June A significant correlation was found between the ESS score 1998 on clinical suspicion of obstructive sleep-apnoea. and RDI (rho=0.28; P < 0.05) and HbSaO2 nocturnal nadir At the first scheduled visit, each patient completed an Italian (rho=−0.37; P < 0.001). version of the ESS, regardless of the presence and degree of The data show that the ESS distinguishes daytime sleepiness complaint of excessive daytime sleepiness at the clinical degree in OSAS patients, simple snorers, and healthy control interview. In each case a doctor sensitized the patient about subjects. It is likely that patient sensitization and prospective the issue of sleepiness before the scale completion, and remained use of the questionnaire improves the scale’s sensitivity. The available for any necessary clarification while the patient was correlation between the ESS score and some instrumental filling in the questionnaires. Within two weeks of completing markers of OSAS suggest that the ESS is a potentially useful the scale, each patient underwent a full night of laboratory or tool in the assessment of OSAS patients. ambulatory polysomnography. The study only considered those patients who received a REFERENCES definite diagnosis of obstructive sleep apnea (OSA) or simple snoring, in accordance with international criteria (Strohl and Douglass, A. B., Bornstein, R., Nino Murcia, G. et al. The Sleep Disorders Questionnaire I. Creation and Multivariate structure of Redlione 1996). Fifty-four subjects (45 males, 9 females, mean SDQ. Sleep, 1994, 17: 160–167. age 51.7, SD 9.8 years, mean Body Mass Index (BMI) 30.1, SD 5.9) received a definite diagnosis of OSAS. The mean Table 1 Correlation between ESS score and age, BMI, RDI, Respiratory Disorder Index (RDI) was 34.4, SD 22. TwentyHbSaO2 nadir: Spearman correlation six per cent of the patients had an RDI between 7 and 15; 24% between 16 and 30; 18% between 31 and 45; and the remaining RDI BMI Age (yr) HbSaO2 nadir 32% over 45. The mean nocturnal HbSaO2 nadir for the group BMI 0.087 of OSAS patients as a whole was 72.6% (SD 14). Age (yr) 0.16 0.09 Twenty patients (mean age 50.3, SD 11 years, 17 males, 3 HbSaO2 nadir −0.47∗∗∗ −0.35∗ −0.31∗ females; mean BMI 26.3, SD 3) were diagnosed as having ESS Tot 0.28∗ 0.30 0.09 −0.37∗∗ simple snoring (mean RDI 1.4, SD 1.6, mean nocturnal HbSaO2 nadir 94%, SD 1.5). ∗ P< 0.05, ∗∗ P< 0.01, ∗∗∗P< 0.001.

Sleep hygiene in adult epilepsy patients: a questionnaire-based survey.

Two hundred and seventy epilepsy patients referred to the Epilepsy Centre of the “C. Mondino” Institute of Neurology and 230 healthy subjects comparable for age, sex and education completed a sleep questionnaire of 112 multiple choice questions including those that concern sleep hygiene practice. The percentage of subjects with habitually inappropriate sleep hygiene habits was significantly higher in controls than in epilepsy patients for 7 out of the 9 sleep hygiene practices considered (P at chi square less than 0.05). No significant relationship between kind and/or severity of epilepsy and the degree of sleep hygiene practice was found. The data show that sleep hygiene practice is more adequate in epilepsy than in control subjects. It is possible that the appropriate sleep hygiene practice of epilepsy patients derives from the fact that they habitually refrain from a lot of practices which possibly aggravate both the course of epilepsy and seizure‐related complications.

Septo-optic dysplasia and psychiatric disorders: a case report.

BackgroundSepto-optic dysplasia, a variable combination of abnormalities of cerebral midline structures, is a clinically heterogeneous syndrome in which the midline defects may be implicated in psychiatric disturbances. ObjectiveTo describe a case of septo-optic dysplasia associated with depression and psychosis and to discuss the role of these developmental abnormalities in psychiatric disturbances. MethodsThe patients clinico-anamnestic, neuroradiologic, neuropsychiatric, endocrinologic, ophthalmologic, and genetic profile was evaluated. ConclusionsDevelopmental abnormalities due to disruption of the complex neural network linking the septum pellucidum with other limbic structures may have been involved in the affective and psychotic disturbances observed in our patient.