ARTICLE
Auteur(s) : Odysseas
Mouzas1, Nikiforos Angelopoulos1, Maria
Papaliagka1, Panagiotis Tsogas2
1Department of Psychiatry, University Hospital of
Larissa, 411 10, Larissa, Greece
2Dermatologist, private practice, Lioufi 3, 50100,
Kozani, Greece
accepté le 11 Octobre 2007
On terviewing patients presenting with vitiligo in an outpatient
dermatological clinic, we noticed that many of them reported that
they had faced sleep problems during their childhood and especially
parasomnias, such as sleepwalking, nocturnal enuresis, sleep
terrors, night illusions and nightmares. We therefore decided to
explore the relationship between vitiligo and parasomnias more
systematically.
Vitiligo is a skin disorder of unknown aetiology, affecting
0.1%-2% of the general population [1]. Concerning the aetiology,
three basic theories have been proposed: the autoimmune theory [2,
3], the autocytotoxic one [4], and the neural function hypothesis
[5, 6], which proposes that a neurotransmitter destroys the
melanocytes or inhibits the production of melanin. Furthermore, a
composite hypothesis has been formulated through a merger of the
three processes [4].
Nocturnal enuresis most commonly presents as a primary sleep
disorder and is extremely common, affecting 15.7% of children
between 3 and 13 years of age [7]. The cause of primary enuresis is
unknown, while secondary enuresis is proposed to be of
psychological origin [8].
Nightmares occur during REM sleep and therefore are more common
during the second half of the night. They may result in awakening
from REM sleep, usually in agitation, with vivid recall of
distressing dream imagery. Occasional nightmares in children are
thought to be common, with an incidence of 25% to 50% [9], and
57.6% in a Swedish study [10].
Sleep terrors are reported in 1% to 6% of the paediatric
population and usually disappear by the age of 6 years [11, 12].
They occur during stage 4 sleep and are typified by an extremely
agitated child, often screaming, with increased heart rate and
dilated pupils. If wakened, the children appear confused and are
usually inconsolable, with no recall of the event [13].
Sleepwalking is common, occurring in 1% to 15% of children and
usually begins when the child is between the ages of 4 and 8 years,
but it can persist into late adolescence and adulthood [14]. A
sleepwalking episode consists of minor actions such as sitting up
in bed, walking around the room or house, or other activities. The
aetiology and pathophysiology of sleepwalking are not well
understood [15, 16]. Genetic, developmental, organic and
psychological factors have been proposed as causes of sleepwalking
[17]. Basseti et al. [18] proposed that sleepwalking could result
from activation of thalamocingulate pathways and persisting
deactivation of other thalamocortical arousal systems. Juszczak and
Swiergiel [19], suggest that the cerebral serotoninergic system may
play an important role in the pathophysiology of sleepwalking. They
also suggest that sleepwalking may be a part of a more generalized
sleep disturbance, including night terrors and nocturnal enuresis.
The contentious hypothesis has also been reported, that
sleepwalking and night terrors are symptomatic of a protective
dissociative mechanism [20].
Cosmetic disfigurement from vitiligo, especially in visible
locations, has psychological consequences in many patients, such as
anxiety, feelings of embarrassment, perception of discrimination
and low self esteem, especially in patients with lower ego
strength, particularly younger ones [21, 22]. Stress on the other
hand, may also potentially affect the evolution of vitiligo via the
increase of catecholamines or via other hormonal pathways [23,
24].
To our knowledge, there do not exist other research studies
investigating the relationship between vitiligo and parasomnias. So
we decided to investigate the relationship between vitiligo and the
existence of parasomnias in the earlier life of patients. Our
research hypothesis was that the vitiligo patients experienced more
parasomnias during childhood and puberty than normal people.
In order to corroborate a specific association, we also
investigated a group of patients with other skin disorders. So, our
second hypothesis was that patients suffering from skin disorders
without a psychogenic origin did not experience parasomnias more
often than the normal population.
Methods and subjects
Our sample was composed of 216 individuals divided in three groups.
Group A consisted of 116 patients suffering from vitiligo and group
B of 52 patients suffering from other dermatological disorders
without psychogenic involvement (such as acne). The control group
(Group C) consisted of 48 partners and relatives of the patients
without dermatological disorders. The dermatological diseases were
diagnosed by dermatologists according to the standards of the
dermatological association. To avoid any effect of the
psychological status of the subjects suffering from vitiligo which
could influence the reports of parasomnias, patients having either
been diagnosed with psychiatric disturbance or receiving
psychiatric treatment were excluded from the sample.
No specific method was used to calculate the numbers of the
individuals in groups B and C. They were selected in order to
satisfy the age matching limitations, to have no psychiatric
diagnosis or psychiatric treatment, and to have consulted the
dermatological clinic during the same period of time as the
subjects suffering from vitiligo.
The mean age of group A was 32.43 years (SD 9.1, min/max:
16/65), of group B 30.84 years (SD 07.9, min/max: 16/44) and the
mean age of group C was 29.48 (s.d.: 10.1, min/max: 16/56). Table 1 shows the distribution of the sample
subjects according to their gender. To detect differences in the
mean age between the three groups, independent t-test was used. No
statistically significant difference was found between the groups.
To detect sex differences between the three Groups, χ2
was applied. There was a statistically significant difference
between group A and group B (χ2: 14.682, df: 1, p:
0.000) and between Group B and Group C (χ2: 6.651, df:
1, p: 0.001). No statistically significant difference was found
between group A and group C.
In place of a clinical interview, all participants were given an
inventory including clinical questions concerning the recollection
(they were asked to remember or ask their family members) about
symptoms of sleep disorders and especially parasomnias during
childhood and adolescence. The questions were closed, such as: did
you experience sleep enuresis as a child?
The data statistical analysis was performed with the aid of the
SPSS 12 statistical packet [25], using the χ2 statistic
method and independent sample t-test.
Table 1 Gender distribution in the three study groups
|
Group A
|
Group B
|
Group C
|
|
Men
|
42 (36.2%)
|
4 (7.7%)
|
13 (27.1%)
|
|
Women
|
74 (63.8%)
|
48 (92.3%)
|
35 (72.9%)
|
|
Total
|
116
|
52
|
48
|
Results
Figure 1
displays the distribution of symptoms in the three groups of the
participants in terms of parasomnias, while table 2 records the results of the χ2
statistic between the three groups concerning parasomnias. Among
the participants of the group A, 43 subjects (37.1%) reported
nocturnal enuresis, 31 (26.7%) reported sleepwalking, 57 subjects
(49.1%) night illusions, 65 (56.0%) sleep terrors and 55 subjects
(47.4%) reported nightmares. The self-reported parasomnias among
the subjects of group B were 12 (23.1%) for nocturnal enuresis, 4
(7.7%) for sleepwalking, 16 (30.8%) for night illusions, 21 (40.4%)
for sleep terrors and 16 (30.8%) for nightmares, while among group
C were 4 (8.3%) for nocturnal enuresis, 1 (2.1%) for sleepwalking,
7 (14.6%) for night illusions, 13 (27.1%) for sleep terrors and 3
(6.3%) for nightmares.
Table 2 demonstrates that vitiligo
sufferers reported statistically significantly more sleep
disorders, and especially sleep walking, nocturnal enuresis, night
illusions, sleep terrors and nightmares, in relation to the control
group. Sufferers from other dermatological diseases demonstrated a
difference, statistically significant in relation to the control
group, only in nightmares and nocturnal enuresis. Furthermore,
vitiligo sufferers demonstrated a difference, statistically
significant in relation to the group B (sufferers from other
dermatological diseases) in nightmares, night illusions and
sleepwalking, while they did not present a statistically
significant difference in sleep terrors and nocturnal enuresis.
To detect differences between males and females in any of the
reported parasomnias by the subjects suffering from vitiligo,
χ2 test was used. A statistically significant difference
was found only for sleep terrors (χ2: 4.780, df: 1, p:
0.046), in agreement with the general population in known
literature [26].
Table 2 Chi-square test results between patients with
vitiligo and others dermatological diseases versus control group
|
Group A/Group C
|
Group A/Group B
|
Group B/Group C
|
|
Parasomnias
|
χ2
|
df
|
p
|
χ2
|
df
|
p
|
χ2
|
df
|
p
|
|
Nocturnal enuresis
|
13.71
|
1
|
.000
|
3.19
|
1
|
.074
|
4.04
|
1
|
.045
|
|
Sleepwalking
|
13.13
|
1
|
.000
|
7.88
|
1
|
.005
|
1.63
|
1
|
.199
|
|
Night illusions
|
17.38
|
1
|
.000
|
5.14
|
1
|
.023
|
3.69
|
1
|
.055
|
|
Sleep terrors
|
11.41
|
1
|
.001
|
3.52
|
1
|
.061
|
1.97
|
1
|
.161
|
|
Nightmares
|
25.17
|
1
|
.000
|
4.08
|
1
|
.043
|
9.75
|
1
|
.002
|
Discussion
The results reported in this study demonstrate that patients with
vitiligo presented specific sleep disorders during their childhood
and adolescence, such as sleepwalking, sleep terrors, nightmares,
night illusions and nocturnal enuresis when compared with the
control group. They further indicate the presence of a strong
correlation between parasomnias in early childhood and adolescence
life and the occurrence of vitiligo later. Simultaneously they
raise important issues concerning the aetiopathogenesis of vitiligo
and of parasomnias as well.
It has generally been reported that vitiligo, as well as
parasomnias, are of unknown aetiopathogenesis. Some theories have
been developed for vitiligo involving catheholamines [27], either
concerning its aetiopathogenesis [6], or its clinical course [4],
and to a large extent, the serotoninergic system of the brain. On
the other hand, it has already been suggested by Juszczak and
Swiergiel [19] that the cerebral serotonergic system may play an
important role in the pathophysiology of sleepwalking, and they
also suggested that sleep walking may be a part of a more
generalized sleep disturbance including night terrors and nocturnal
enuresis and can share a common pathophysiological substrate [28].
Our results, therefore, could be explained and supported by these
theories.
Our study may indicate that vitiligo patients had experienced a
significant degree of disturbed sleep, possibly further indicating
a significant degree of emotional distress, during their childhood
or adolescent life [29]. Sufferers from other dermatological
diseases also seem to display signs of disturbed sleep/emotion
earlier in their life, only to a lesser extent compared to vitiligo
patients. The fact that vitiligo patients seem to have been more
distressed during their early years than patients with other
dermatological diseases might imply a difference in
aetiopathogenesis of vitiligo, potentially associated with a higher
degree of emotional distress. It might also reflect the limitations
of our study, such as the smaller number of patients in group B, or
the difference in the ratio of male to female patients in groups A,
B, or might raise the question of a better clarification of group B
as far as which dermatological diseases can truly be considered
“without psychogenic involvement”.
The results of our study raise questions needing further and
more systematic research such as: 1) are catecholamines (especially
the serotoninergic system) involved in the aetiopathogenesis of
vitiligo, 2) is vitiligo related with other psychiatric disorders
in which catecholamines are involved, such as depression, and 3) is
there a possibility of prompt diagnosis of vitiligo in children and
adolescents with parasomnias.
Acknowledgements
Financial support: none. Conflict of interest: none.
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