EEG sleep "abnormalities" in preadolescent boys with a diagnosis of conduct disorder

Assessment of subjective sleep quality and issues in aggression: Intermittent Explosive Disorder compared with psychiatric and healthy controls

BACKGROUND

While prior research has linked clinical sleep issues and aggression, little is known about how clinical sleep issues among individuals with Intermittent Explosive Disorder (IED), which is characterized by a pervasive pattern of impulsive aggression and associated with consequences across multiple life-domains. The present study aims to examine clinical sleep issues among individuals with IED in contrast to individuals with other psychopathology and healthy controls.

METHODS

257 adults, including 100 healthy controls, 85 psychiatric controls and 72 individuals with IED, took part in this study. Participants completed the Structured Clinical Interview for DSM-V Diagnoses, Assessment of clinical sleep issues included the Pittsburgh Sleep Quality Inventory (PSQI), obstructive sleep apnea (OSA) screening, and the Epworth Sleepiness Scale (ESS) as well as assessments of aggression and impulsivity.

RESULTS

IED study participants reported significantly worse sleep quality, increased sleep latency, greater daytime sleepiness and symptoms of OSA. Daytime sleepiness and sleep quality was correlated with impulsivity and aggression.

CONCLUSIONS

This study suggests that individuals with IED have clinically relevant sleep anomalies, and that these are directly associated with measures of impulsivity and aggression. Clinicians treating aggressive individuals are advised to assess and treat such individuals for sleep issues.

Depressive symptoms and poorer performance on the Stroop Task are associated with weight gain

OBJECTIVE

Executive function impairments and depression are associated with obesity but whether they predict weight gain is unclear.

METHODS

Forty-six individuals (35m, 37±10y) completed the Stroop Task, Iowa Gambling Task (IGT), Wisconsin Card Sorting Task (WCST), Inventory for Depressive Symptomatology (IDS-SR), Physical Anhedonia Scale (PAS), and Perceived Stress Scale (PSS). Body composition (DXA) and fasting glucose were also measured. Data from return visits were used to assess changes in weight.

RESULTS

Poorer Stroop and WCST performance associated with higher BMI whereas poorer IGT and WCST performance associated with higher body fat (%; all p's≤0.05). Stroop interference (p=0.04; p=0.05) and IDS-SR (p=0.06; p=0.02) associated with increased BMI and weight gain (%/yr). In a multivariate linear model Stroop interference (β=0.40, p<0.01; β=0.35, p<0.01) and IDS-SR (β=0.38, p<0.01; β=0.37, p<0.01) independently predicted increased BMI and weight gain (%/yr) even after controlling for baseline weight and glucose levels.

CONCLUSIONS

Poorer response inhibition and depressive symptoms, but not glucose levels, predicted weight gain. Evaluating neurocognitive and mood deficits could improve current treatment strategies for weight loss. Clinical Trial Registration Numbers NCT00523627, NCT00342732, NCT01224704. clinicaltrials.gov.

QEEG and LORETA in Teenagers With Conduct Disorder and Psychopathic Traits

BACKGROUND

Few studies have investigated the impact of the psychopathic traits on the EEG of teenagers with conduct disorder (CD). To date, there is no other research studying low-resolution brain electromagnetic tomography (LORETA) technique using quantitative EEG (QEEG) analysis in adolescents with CD and psychopathic traits.

OBJECTIVE

To find electrophysiological differences specifically related to the psychopathic traits. The current investigation compares the QEEG and the current source density measures between adolescents with CD and psychopathic traits and adolescents with CD without psychopathic traits.

METHODS

The resting EEG activity and LORETA for the EEG fast spectral bands were evaluated in 42 teenagers with CD, 25 with and 17 without psychopathic traits according to the Antisocial Process Screening Device. All adolescents were assessed using the DSM-IV-TR criteria. The EEG visual inspection characteristics and the use of frequency domain quantitative analysis techniques (narrow band spectral parameters) are described.

RESULTS

QEEG analysis showed a pattern of beta activity excess on the bilateral frontal-temporal regions and decreases of alpha band power on the left central-temporal and right frontal-central-temporal regions in the psychopathic traits group. Current source density calculated at 17.18 Hz showed an increase within fronto-temporo-striatal regions in the psychopathic relative to the nonpsychopathic traits group.

CONCLUSIONS

These findings indicate that QEEG analysis and techniques of source localization may reveal differences in brain electrical activity among teenagers with CD and psychopathic traits, which was not obvious to visual inspection. Taken together, these results suggest that abnormalities in a fronto-temporo-striatal network play a relevant role in the neurobiological basis of psychopathic behavior.

Sleep in children with disruptive behavioral disorders

This study compared sleep in patients with Conduct Disorder/Oppositional Defiant Disorder (CD/ODD) and normative children and evaluated the associations between sleep and behavioral symptoms in patients. Participants were 30 patients, aged 7 to 12 years, with diagnoses of CD/ODD and their age and gender matched controls. Patients with CD/ODD and their parents reported significantly more sleep problems than did the control children and their parents (p values < 0.01). By actigraphy, CD/ODD children with comorbid ADHD slept significantly less than did the patients with CD/ODD alone and the controls. In patients, low sleep amount and efficiency associated with increased amount of parent-reported externalizing symptoms (r = -0.72, 0.66, p values < 0.001). Results highlight the need of evaluating sleep in children with CD/ODD. Improving their sleep may ease their symptoms.

Poor sleep as a potential causal factor in aggression and violence

Clinical observations suggest that sleep problems may be a causal factor in the development of reactive aggression and violence. In this review we give an overview of existing literature on the relation between poor sleep and aggression, irritability, and hostility. Correlational studies are supporting such a relationship. Although limited in number, some studies suggest that treatment of sleep disturbances reduces aggressiveness and problematic behavior. In line with this is the finding that sleep deprivation actually increases aggressive behavior in animals and angriness, short-temperedness, and the outward expression of aggressive impulses in humans. In most people poor sleep will not evoke actual physical aggression, but certain individuals, such as forensic psychiatric patients, may be particularly vulnerable to the emotional dysregulating effects of sleep disturbances. The relation between sleep problems and aggression may be mediated by the negative effect of sleep loss on prefrontal cortical functioning. This most likely contributes to loss of control over emotions, including loss of the regulation of aggressive impulses to context-appropriate behavior. Other potential contributing mechanisms connecting sleep problems to aggression and violence are most likely found within the central serotonergic and the hypothalamic-pituitary-adrenal-axis. Individual variation within these neurobiological systems may be responsible for amplified aggressive responses induced by sleep loss in certain individuals. It is of great importance to identify the individuals at risk, since recognition and adequate treatment of their sleep problems may reduce aggressive and violent incidents.

Sleep in conduct-disordered adolescents--a polysomnographic and spectral power analysis study

The aim of the present study was to characterize sleep in conduct-disordered adolescents using polysomnography and spectral power analysis. The two hypotheses were that conduct disorder would be associated with objective sleep problems, and that conduct disorder--as a precursor of adult antisocial personality disorder--would be associated with the same kind of abnormal sleep architecture, with both increased deep sleep and delta power, as previously reported in antisocial personality disorder. The patients consisted of 15 adolescents (age range 13-17 years, mean age 14.7 years) with histories of antisocial behavior so functionally impairing that they were ordered by child welfare to undergo a psychosocial evaluation in a closed social services ward. The healthy age-matched controls comprised 20 volunteers recruited with a newspaper advertisement. Opposite to earlier subjective sleep studies among conduct-disordered children, no significant differences in sleep parameters were observed between the two groups. The adolescents with conduct disorder slept a little bit longer, but the percentage amount of different sleep stages did not differ significantly between the two groups. Relative spectral power of sleep, delta power in particular, was similar in both groups, assessed in total sleep time as well as in first half of it. Different alternative explanations for these findings are discussed.

Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity

STUDY OBJECTIVES

To review medical and legal case reports to determine how many appear to support the belief that violence against other individuals that occurs during Disorders of Arousal - sleepwalking, confusional arousal, and sleep terrors - is triggered by direct physical contact or close proximity to that individual and does not occur randomly or spontaneously.

DESIGN

Historical review of case reports in the medical and legal literature.

MEASUREMENTS AND RESULTS

A total of 32 cases drawn from medical and legal literature were reviewed. Each case contained a record of violence associated with Disorders of Arousal; in each, details of the violent behavior were available. Violent behaviors associated with provocations and/or close proximity were found to be present in 100% of confusional arousal patients and 81% of sleep terror patients. Violent behaviors were associated with provocation or close proximity in 40%-90% of sleepwalking cases, depending on whether the legal verdict and other factors were taken into account. Often the provocation was quite minor and the response greatly exaggerated. The specific manner in which the violence was triggered differed among sleepwalking, confusional arousals, and sleep terrors.

CONCLUSIONS

In the cases reviewed, violent behavior directed against other individuals associated with Disorders of Arousal most frequently appeared to follow direct provocation by, or close proximity to, another individual. Sleepwalkers most often did not seek out victims, but rather the victims sought out or encountered the sleepwalker. These conclusions are tempered by several limitations: the selection of cases was not random and may not represent an accurate sample of violent behaviors associated with Disorders of Arousal. Also, final verdicts by juries in reported legal cases should not be confused with scientific proof of the presence or absence of sleepwalking. The pathophysiology of Disorders of Arousal with and without violent behavior could be associated with normally occurring deactivation of the frontal lobes during slow wave sleep (SWS) connected via atypically active thalamocortical pathways to the limbic areas. It is not known if the violent sleepwalker, confusional arousal patient, or sleep terror patient differs from other patients with these disorders. The conclusions of this case series await confirmation by the results of future sleep laboratory based studies.

Increased deep sleep in a medication-free, detoxified female offender with schizophrenia, alcoholism and a history of attempted homicide: effect of concomitant administration of quetiapine and citalopram

BACKGROUND

An increased amount of deep sleep has been shown to be associated with antisocial personality disorder. This phenomenon has also been observed in a habitually violent female offender with schizophrenia and alcohol dependence.

AIM

To evaluate sleep patterns in this patient and compare them with those of healthy, pro-social women of similar age, and in the same patient over time after treatment.

METHOD

Multiple measures of sleep were taken over two consecutive nights with the presenting patient and with three age-matched healthy women. One year after the patient was established on atypical antipsychotic (quetiapine), and antidepressant (SSRI) medication (citalopram) her sleep evaluation was repeated. In each case only the second night's recordings were used in analyses.

RESULTS

The patient differed significantly from the three healthy women on most sleep measures. After a year on the medication, the patient's sleep had improved and the non-REM sleep measures had come into the normal range. She had also shown a sustained clinical and behavioural improvement.

DISCUSSION AND IMPLICATIONS

The literature suggests that both drugs had a part to play in the improvements in sleep, symptomatology and behaviour. The possibility that improvement in deep sleep is secondary to citalopram and that it is this that was specifically associated with violence reduction seems worthy of further study.

Increased deep sleep in a medication-free, detoxified female offender with schizophrenia, alcoholism and a history of attempted homicide: case report

BACKGROUND

Psychiatric sleep research has attempted to identify diagnostically sensitive and specific sleep patterns associated with particular disorders. Both schizophrenia and alcoholism are typically characterized by a severe sleep disturbance associated with decreased amounts of slow wave sleep, the physiologically significant, refreshing part of the sleep. Antisocial behaviour with severe aggression, on the contrary, has been reported to associate with increased deep sleep reflecting either specific brain pathology or a delay in the normal development of sleep patterns. The authors are not aware of previous sleep studies in patients with both schizophrenia and antisocial personality disorder.

CASE PRESENTATION

The aim of the present case-study was to characterize the sleep architecture of a violent, medication-free and detoxified female offender with schizophrenia, alcoholism and features of antisocial personality disorder using polysomnography. The controls consisted of three healthy, age-matched women with no history of physical violence. The offender's sleep architecture was otherwise very typical for patients with schizophrenia and/or alcoholism, but an extremely high amount of deep sleep was observed in her sleep recording.

CONCLUSIONS

The finding strengthens the view that severe aggression is related to an abnormal sleep pattern with increased deep sleep. The authors were able to observe this phenomenon in an antisocially behaving, violent female offender with schizophrenia and alcohol dependence, the latter disorders previously reported to be associated with low levels of slow wave sleep. New studies are, however, needed to confirm and explain this preliminary finding.

Human impulsive aggression: a sleep research perspective

Impulsive aggression is commonly associated with personality disorders, in particular antisocial and borderline personality disorders as well as with conduct disorder and intermittent explosive disorder. The relationship between impulsive aggression and testosterone is well established in many studies. One of the aims of this study was to characterize the relationship between earlier-mentioned different categorical psychiatric diagnosis describing human impulsive aggression and sleep using polysomnography and spectral power analysis. Another aim was to study the relationship between serum testosterone and sleep in persons with severe aggressive behaviour. Subjects for the study were 16 males charged with highly violent offences and ordered for a pretrial forensic psychiatric examination. The antisocials with borderline personality disorder comorbidity had significantly more awakenings and lower sleep efficiency compared with the subjects with only antisocial personality disorder. The subjects with severe conduct disorder in childhood anamnesis had higher amount of S4 sleep and higher relative theta and delta power in this sleep stage compared with males with only mild or moderate conduct disorder. The same kind of sleep architecture was associated with intermittent explosive disorder. In subgroups with higher serum testosterone levels also the amount of S4 sleep and the relative theta and delta power in this sleep stage were increased. The study gives further support to the growing evidence of brain dysfunction predisposing to severe aggressive behaviour and strengthens the view that there are different subpopulations of individuals with antisocial personality varying in impulsiveness. The differences in impulsiveness are reflected in sleep architecture as well.

Depressive symptoms and cigarette smoking predict development and persistence of sleep problems in US adolescents

OBJECTIVE

To evaluate factors related to the development and persistence of adolescent sleep problems.

METHODS

In this longitudinal, population-based study, the Teenage Attitudes and Practices Survey was administered by telephone to 7960 adolescents (3921 girls and 4039 boys) 12 to 18 years old in 1989 and at follow-up in 1993. Sleep problems at both time points were assessed using a single item on the Teenage Attitudes and Practices Survey. Those who responded that they "often or sometimes" had trouble going to sleep or staying asleep during the past 12 months were categorized as reporting sleep problems, whereas those who responded "often" were categorized as having frequent sleep problems. Multiple logistic regression analyses were used to identify baseline characteristics predictive of the development and persistence of sleep problems or frequent sleep problems, respectively, from baseline to follow-up.

RESULTS

Of the 4866 adolescents without sleep problems at baseline, 28% developed sleep problems by 1993, and 9% developed frequent sleep problems. Of the 3094 adolescents who reported sleep problems at baseline, 52% reported sleep problems in 1993, and 21% reported frequent sleep problems. Female sex and notable depressive symptoms were associated with the development and persistence of sleep problems and frequent sleep problems at follow-up. Cigarette smoking status showed a dose-response relationship with development of sleep problems and frequent sleep problems, and with persistence of frequent sleep problems at follow-up.

CONCLUSION

The reduction of depressive symptoms and cigarette smoking among adolescents are important factors to consider in prevention and treatment efforts focused on adolescent sleep problems.

Sleep disturbances in children with attention-deficit/hyperactivity disorder

OBJECTIVE

To evaluate the relationship between sleep disturbances and attention-deficit/hyperactivity disorder (ADHD).

METHOD

Empirical research published since 1970 on sleep disturbances in children with ADHD was systematically reviewed. A "box-score" approach was used to examine consistency of findings across the studies, which used different outcome measures.

RESULTS

Although subjective accounts of sleep disturbances in ADHD were prevalent, objective verification of these disturbances was less robust. The only consistent objective findings were that children with ADHD displayed more movements during sleep but did not differ from normal controls in total sleep time. An additional finding was that stimulant medication led to changes in the children's sleep (e.g., prolonged sleep latency, increased length of onset to first rapid eye movement cycle), but these changes were believed to be nonpathological.

CONCLUSIONS

The exact nature of the sleep problems in children with ADHD remains to be determined. Many of the relevant issues have not been adequately addressed. Factors such as poorly defined diagnostic groups, small sample sizes, few studies, and methodological and procedural limitations make it difficult to determine the relationship between ADHD and sleep problems.

Practitioner review: assessment and treatment of sleep disorders in children and adolescents

Sleep disorders in children are diverse in type, common, often serious in their effects yet neglected in professional education. They complicate many psychiatric disorders and can cause various cognitive and behavioural problems as well as more widespread difficulties in the family as a whole. Accurate assessment allows an appropriate choice from the various types of treatments that are now available but often under used. Diagnostic points and treatment approaches are outlined for the three main categories of childhood sleep disorder: sleeplessness; excessive sleepiness; and episodic disturbances related to sleep (parasomnias). The need for more widespread awareness of and provision for sleep disorders is emphasized.

Hypnopolygraphic alterations in Attention Deficit Disorder (ADD) children

The sleep pattern of 13 prepubertal children, nonmedicated, rigourously diagnosed as Attention Deficit Disorder (ADD) was recorded for two consecutive nights. Analyses of sleep pattern variables revealed a marked reduction of sleep onset latency (p less than .01), a great number of nocturnal awakenings (p less than .01), and a high increase of Delta sleep percentage (p less than .01) for the ADD children compared to normals. In addition, the two subtypes of the disorder--ADD with hyperactivity (ADD/H) and ADD without hyperactivity (ADD/WO) or ADD undifferentiated--showed distinct hypnopolygraphic correlates. Those ADD/H children had a greater sleep fragmentation and a lesser degree of sleep efficiency. These findings would support the hypothesis that ADD is related to a deficient control of arousal level and, on the other hand, suggest that ADD/H and ADD/WO are different clinical entities.

Application of automated REM and slow wave sleep analysis: I. Normal and depressed subjects

Computerized analysis of rapid eye movement (REM) and delta electroencephalographic (EEG) sleep patterns in normal and depressed subjects offers opportunities to examine sleep more precisely than previously possible. In the present study, automated REM analyses demonstrated good reliability with traditional manual procedures in both normal and depressed subjects. However, automated delta analyses correlated well with traditional scoring in normal subjects, but not in depressed patients. These findings suggest the use of automated delta techniques similar to those employed in this report or spectral analytic techniques in the following types of studies: specificity of delta sleep in various psychiatric syndromes, changes in delta sleep produced by the administration of psychotropic agents, relationships between delta sleep and sleep-related neuro-endocrine patterns, and, finally, relationships between delta sleep patterns and other biological rhythms such as activity and temperature.