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mise à jour du
2 juillet 2007
Acta Psychiatr Scand
2007: 1
Excessive yawning is common
in the bulbar-onset form of ALS
Paul Wicks
Centre for Neurodegeneration Research
King's College London Institute of Psychiatry

Chat-logomini

I was interested to read Gutierrez-Alvarez's case report Do your patients suffer from excessive yawning (1), describing two patients with uncontrollable yawning resulting from SSRI treatment. Excessive yawning has also been described as a presenting feature of stroke to the lower brain stem (2), as well as occurring in neurodegenerative conditions including multiple sclerosis (3) and progressive supranuclear palsy (4).
 
During my PhD research, I noticed several patients with amyotrophic lateral sclerosis (ALS) reporting excessive yawning which could be extremely painful, leading in some cases to dislocation of the jaw. However, it was not feasible to survey a large sample of patients without incurring significant costs.
 
PatientsLikeMe.com is an advanced web site which allows patients with ALS to track their symptoms, treatments, and progression, and share this data with other patients.
 
In order to assess the prevalence of excessive yawning in this population, patients were asked to complete a brief symptom survey. Participation was voluntary and patients were informed that their data would be submitted as a publication.
 
Using a systemwide invitation to participate in research, patients were asked to endorse whether they experienced none, mild, moderate, or severe excessive yawning, described as attacks of uncontrollable yawning, sometimes when (you) are not even tired.
 
From a total of 539 ALS patients tracking their data, 254 (47%) completed the survey on excessive yawning. Excessive yawning was reported to be absent in 75 patients (30%) mild in 75 (30%), moderate in 81 (32%), and severe in 22 (9%). Using Spearman's Rho there was no correlation between severity of yawning and age (r 1/4 )0.63, P 1/4 0.329, n 1/4 244) months since diagnosis (r 1/4 )0.032, P 1/4 0.619, n 1/4 250), or the last recorded measurement of forced vital capacity (r 1/4 )0.136, P 1/4 0.99, n 1/4 148). There was no association between yawning severity and anti-depressant usage (v2 1/4 3.269, P 1/4 0.352).
 
However, there was an association between yawning severity and site of onset (v2 1/4 18.705, P 1/4 0.028). Patients with a bulbar onset of disease were more likely (57%) to have moderate or severe yawning than patients with an arm onset (42%) or leg onset (31%). Two patients with a respiratory onset reported moderate excessive yawning. Excessive yawning has previously been reported as a presenting sign of ALS (5) and was theorised to be a marker of degeneration in the upper motor neurones.
 
However, it was also noted that loss of the bulbar nuclei would eventually lead to patients inability to yawn. Interestingly, Williams patient responded favourably to a low dose of the neuroleptic thioridazine. A more thorough future investigation could involve a sleep study including measurements of oxygen saturation and a measure of daytime sleepiness.
 
Surveys of neurological patients using the Patients- LikeMe system represent a rapid and efficient method for data collection in rare diseases.
 
The mechanisms of speech and deglutition in progressive bulbar palsy. Critchley MD, Kubik C. 1925 
 
References
1. Gutierrez-Alvarez AM. Do your patients suffer from excessive yawning? Acta Psychiatr Scand 2007;115:80&endash;82.
 
2. Cattaneo L, Cucurachi L, Chierici E, Pavesi G. Pathological yawning as a presenting symptom of brain stem ischaemia in two patients. J Neurol Neurosurg Psychiatry 2006;77:98&endash; 100.
 
3. Postert T, Pohlau D, Meves S, Nastos I, Przuntek H. Pathological yawning as a symptom of multiple sclerosis. J Neurol 1996;243:300&endash;301.
 
4. Sandy KR. Excessive yawning and progressive supranuclear palsy. Int J Neurosci 1987;34:123&endash;124
 
5. Williams DR. The yawning reflex: an upper motor neuron sign in amyotrophic lateral sclerosis. Neurology 2000; 55:1592&endash;1593.
 
Louwerse E Forced yawning as a pseudobulbar sign in amyotrophic lateral sclerosis J Neuroscience Research 1998, sup, 392
 
PatientsLikeMe.com est un site internet qui permet à des malades atteints de sclérose latérale amyotrophique ou maladie de Charcot de reconnaître les symptômes, les traitements et l'évolution de leur maladie et de partager ces informations avec d'autres malades.
 
Plusieurs patients ont ainsi signalé des bâillements de fréquence excessive, souvent perçus de façon pénible, et parfois responsables de luxation mandibulaire.
 
Sur un total de 539 malades atteints de SLA, 254 (47%) ont complété un questionnaire.
 
Des bâillements excessifs ont été comme inexistants chez 75 (30%), peu importants chez 75 (30%), modérés chez 81 (32%) et sévères chez 22 (9%).
 
Il n'a pas été retrouvé d'association entre bâillements trop nombreux et usage d'antidépresseurs.
 
Par contre, il ressort nettement une association entre localisation initiale de la maladie et sévérité du nombre des bâillements. 57% des patients atteint de forme initiale bulbaire déclarait souffrir de bâillements modérés ou sévères alors que ce phénomène n'est rapporté que par 42% des patients initiallement atteint au membre supérieur et 31% des patients touchés au membre inférieur. Deux malades présentant des signes ventilatoires ont signalés des bâillements sévères.
 
Des bâillements de fréquence excessive ont déjà été rapportés antérieurement comme symptôme initial de cette maladie et rapportés comme un marqueur de la dégénerescence des moto-neurones bulbo-pontiques. Pourtant, il a été aussi noté que la perte fonctionnelle des noyaux bulbaires entrainait la disparition des bâillements.
 
Williams rapporte que ses patients bâilleurs étaient apaisés par de faibles doses de thirodazine. Quoiqu'il en soit des recherches futures devront prendre en compte une polysomnographie avec mesure de la saturation en oxygène (recherche d'apnées du sommeil) et mesure de la somnolence diurne.
 
Yawning as a side-effect of antidepressant therapy