- 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
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