Psiquiatria - Faculdade de Medicina - UFMG

CONSIDERING THE SLEEP APNEA HIPOPNEA RERA SYNDROME IN THE
DIFFERENTIAL DIAGNOSE OF PSYCHIATRIC DISORDERS
CONSIDERANDO A SÍNDROME DE APNÉIA HIPOPNÉIA ARER NO
DIAGNÓSTICO DIFERENCIAL DE TRANSTORNOS PSIQUIÁTRICOS
Dirceu de Campos Valladares Neto*
Summary
It is not rare to see patients complaining to the psychiatrist of
depression, insomnia, apathy, lack of motivation and hypersomnia
who do not respond to antidepressants (AD). Obstructive sleep
apnea hypopnea syndrome (OSAHS) with respiratory effort-related
arousal (RERA) is frequently not considered in the differential diagnosis
or as a second diagnostic, which can lead to frustration to both
doctors and patients. OSAHS is not a rare condition, affecting 4% to
6% of the general population. In Brazil six to eight million people suffer
from OSAHS, most of them not diagnosed or misdiagnosed and
incorrectly treated. OSAHS is also associated with infarct of myocardial,
strokes, hypertension, a seven fold risk in automobile accidents
and represents a social burden.The purpose of presenting this case
is to call attention for OSAHS in the psychiatric population due to a
tendency to obesity for using neuroleptics and AD, and due to the
frequent use of benzodizepines, which are prohibited to OSAHS
patients for relaxing the muscles during sleep and worsening the
condition. Herein we present a case history of an 56 years old
OSAHS patient who already had stroke, infarct of myocardial and
suffered somnolence during the day, lack of motivation, apathy,
depression, initial insomnia and memory difficulties.
Key-words: OSAHS, Depression, RERA, Insomnia,
Benzodiazepines, AD, Apnea, Anxiety, Dementia.
Case history
A 63-year-old retired lawyer presented at our sleep disorder
center complaining excessive daytime sleepiness that appeared to
be related to his very disturbed nighttime sleep. He weighed
74 kilos, which was a normal weight for his height and age but he
was a loud snorer and his wife noticed “apneic episodes” during
sleep. He already had a stroke five years ago which reduced
the movements of his right arm. He also had a myocardial
infarct three years ago. Lack of motivation, apathy, depression
and memory difficulties were also present. He fulfilled the diagnostic
criteria of major depression episode (DSM-IV) and was in
use of AD (maprotiline, 75 mg/day) and a hypnotic (flurazepan,
30 mg/day).
He underwent all-night polysomnography, which showed a
total sleep time of only 204 minutes with a sleep efficiency of
* Psychiatrist, sleep disorders clinican, member of the American
Academy of Sleep Medicine.
56%. He also displayed breathing disturbances during sleep. It
was scored 35 apneic/ hipopneic episodes per hour, his dessaturation
oxigen level was at the range of 64% and 95%, with a
mean of 89 ± 6,7%. He presented more than 370 arousals during
the night that were evident on the electroencephalogram during
sleep (Figure 1).
This findings led to a diagnosis of obstructive sleep hipopnea
apnea syndrome. The patient started to use a CPAP (continuous
positive airway pressure device) during sleep time which dramatically
improved the quality of his nighttime sleep (Figure 2) and
diminished his tendency for daytime sleepiness. It also improved
his mood, his level of energy and his blood pressure, decreasing
its rates. He also noticed improvement of his memory skills.
Discussion
Sleep-related breathing disorders (SRBD)- breathing disorders
that are induced or exacerbated during sleep - are very common.1,2
There is a positive relation between SRBD and obesity
and between SRBD and aging, although SRBD can occur in those
not obese and in all ages.1 It occurs twice in man compared to
woman but this gender difference tends to be reduced or even
matched within elderly people. Mood swings, depression, apathy,
anxiety, difficulty in beginning sleep, insomnia in general and irritability
are commonly seen in such patients.2
Although many different respiratory disorders are affected by
sleep, the three main syndromes associated with sleep are
obstructive sleep apnea syndrome, central sleep apnea syndrome
and the central alveolar hypoventilation syndrome.
The obstructive sleep apnea syndrome is characterized by
upper airway obstruction that occurs during sleep, leading to a
change in the arterial blood gases. Hypoxemia produces cardiac
effects and disrupts sleep, leading to the development of excessive
sleepiness during the day. Insomnia at the beginning or
during sleep can also be present, mainly in the aged (Table 1).3
Central sleep apnea syndrome is characterized by cessation of
breathing that occurs without upper airway obstruction and leads
to blood gas changes that also can produce disrupted sleep and
daytime sleepiness. Patients with a pure preponderance of central
events in the absence of Cheyne-Stokes breathing are sufficiently
rare, so that the existence of idiopathic central sleep apnea syndrome
as a separate clinical entity is open to question. In reality
most patients present with a combination of obstructive and central
events with the former predominating.3
Endereço para correspondência:
Clínica do Sono
Alameda do Ingá 780
34000-000 - Nova Lima - MG
E-mail: dirceu@clinicadosono.com.br
Casos Clin Psiquiat 1999; 1(1):43-45 43