Case of head banging that continued to adolescence
Abstract
Abstract Head banging is a rhythmic movement disorder (RMD) along with headrolling and bodyrolling. The average age of onset is 9 months, and by 10 years of age the majority of subjects no longer complain of head banging. A case of head banging in which the symptoms continued to adolescence is reported. The RMD involved the patient abnormally rolling his body or head and hitting his head on walls during sleep. His head bangings were observed during sleep stage 2 and REM sleep. Doses of clonazepam ranging from 0.5 mg to 2 mg were administered for the RMD, which diminished when treated with 2 mg of clonazepam.
INTRODUCTION
The International Classification of Sleep Disorders defines rhythmic movement disorder (RMD) as a group of stereotyped, repetitive movements involving large muscles, usually of the head and neck, that typically occur immediately prior to sleep onset and are sustained into light sleep.1 The average age of onset is 9 months but by 10 years of age the majority of subjects no longer complain of head banging.2
CASE HISTORY
A 15-year-old male decided to enter a special class when he consulted a doctor. His case history indicated that there had been no problems during his fetal or delivery stage, but his mother had refused to nurse him and he had often been confined to his room. At the age of 3 years, his speech development was found to be retarded. His great grandmother took care of him after his parents divorced and, since that time, he has rolled his head during sleep almost every night. A paediatrician was consulted but no abnormality was indicated. Even after entering junior high school, the patient’s head rolling did not improve. After his mother remarried when he was aged 14 years, his impulse-buying started. He became a habitual thief, which led to his custody in the child consultation centre. The RMD were observed 2 days after entering the child consultation centre. The RMD involved abnormally rolling his body or head and hitting his head on walls during sleep. He was referred to a paediatrician at the centre for examination.
RESULTS AND DISCUSSION
Rhythmic movement disorders may persist in approximately 30% of head bangers up until the age of 4 years, but the condition usually stops by age 10 years.2 A report has shown that it is associated more often with mental retardation, autism, or other significant pathological conditions when the disorders persist into childhood or thereafter.1 We encountered a case of head banging whose symptoms persisted into adolescence. Laboratory investigations, brain computed tomography, magnetic resonance image and resting electroencephalography done on admission showed no abnormalities. The patient’s IQ was 71, falling in the borderline range. Since his admission, episodes of head banging or head rolling RMD, which continued for a few minutes, have occurred, usually during sleep stage 2 and REM sleep. To treat the RMD, clonazepam was administered at doses ranging from 0.5 mg to 2.0 mg. Although the RMD diminished with 2 mg of clonazepam (Table 1), % stage 4 sleep and % stage rapid eye movement (REM) sleep decreased and % stage 2 sleep increased markedly. The pharmacological effects of clonazepam suppressed slow wave sleep (SWS) and REM sleep. Reduced RMD during stage 2 sleep indicates that the decrease is not associated with the propensity to sleep after clonazepam administration. The specific action mechanism of clonazepam on RMD is not known, but it is likely that it partially reflects a serotonergic property.3 Some attempts to treat RMD with benzodiazepines have met with success. For example, oxazepam was used in an 8-year-old, well-adjusted female who had shown body rocking and head banging since the age of 7 months.4 Tricyclic antidepressants have also been used for treating head banging.5 We decided to treat the head banging of the present patient with clonazepam because it has been used successfully to treat other sleep movement disorders (e.g. restless leg syndrome and REM behavior disorder). The initial dose of 0.5 mg was ineffective in decreasing the intensity and frequency of the RMD, but a dosage of 2.0 mg of clonazepam reduced symptoms.
| Before treatment | After treatment | |||||
|---|---|---|---|---|---|---|
| Sleep stage | No. epochs recorded | % TST | No. head bangings | No. epochs recorded | % TST | No. head bangings |
| Wake | 116 | 84 | ||||
| Stage 1 | 24 | 1.95 | 0 | 15 | 1.15 | 0 |
| Stage 2 | 608 | 49.31 | 5 | 971 | 74.18 | 2 |
| Stage 3 | 94 | 7.62 | 0 | 80 | 6.11 | 0 |
| Stage 4 | 198 | 16.06 | 0 | 49 | 3.74 | 0 |
| REM | 309 | 25.06 | 2 | 194 | 14.82 | 1 |
| Movement | 57 | 34 | ||||
- TST, total sleep time; REM, rapid eye movement.
