Psychiatric onset of multiple sclerosis

Psychoses onset in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Psychotic symptoms in multiple sclerosis (MS) have been infrequently studied, despite the existence of numerous case reports showing inconsistent findings. Our aim was to assess the timing of psychosis onset and examine its characteristics in MS cases.

MATERIAL AND METHODS

We conducted a systematic review and meta-analysis according to PRISMA 2020. We searched for case reports and case series of psychosis in MS on MEDLINE through PubMed, Google Scholar, Web of Science, and Cochrane. SPSS 26 was used to perform the data analysis.

RESULTS

Overall, 43 cases were reviewed. Bipolar disorder and schizophrenia (SCZ) were the most frequently observed types. Psychosis was often present before or at the time of MS diagnosis. For patients with prior psychosis before MS diagnosis, those with SCZ were less likely to develop neurologic symptoms compared to those with other psychosis types. Polymorphic delusions were significantly associated with psychosis onset either after or concurrently with MS. Extensive periventricular white matter lesions, cerebellar peduncles, and cerebellar lesions were significantly associated with the onset of psychosis following MS diagnosis. Resistant-treatment psychosis occurred in 59.4% of cases. A favorable outcome was significantly more common in patients with relapsing-remitting MS compared to those with other forms of MS.

CONCLUSION

Our study highlights the importance of considering MS in patients with psychoses, especially those with SCZ or treatment-resistant psychosis. Some white matter lesions may trigger psychosis after MS diagnosis. While managing psychosis in MS can be challenging, MS-specific treatments have proven effective.

Neuropsychological profile of a patient with multiple sclerosis and psychiatric symptoms that masked and delayed the diagnosis. A case report using teleneuropsychology

Objective: Multiple sclerosis (MS) may include not only severe neurological signs and symptoms, but also cognitive and psychiatric disturbances. When psychiatric symptoms precede or are comorbid with MS, it poses a clinical challenge, because it may lead to a mistaken diagnosis of MS as a psychiatric disorder, delaying proper treatment. We describe the neuropsychological profile of a female patient with MS whose diagnosis was delayed due to neuropsychiatric symptoms. Method: A comprehensive analysis of the medical history and the results of a teleneuropsychological assessment of a 36-year-old Mexican woman with a diagnosis of relapsing--remitting MS (RRMS) was performed. Results: The patient indicates a long history of psychotic, anxious, and depressive features years before the first neurological symptom that led to MS going unnoticed for several years. Language, attentional, perceptual, motor, and learning skills were found to be preserved. Short-term memory and spatial orientation problems were identified, with decreased processing speed and executive dysfunction, including working memory and planning deficits. Conclusions: The patient has a non-typical presentation of neuropsychological alterations with cognitive and behavioral symptoms that resemble dorsolateral frontal lobe syndrome. This case study highlights the importance of considering MS in differential diagnosis of patients with psychiatric symptoms, even in the absence of obvious neurological signs.

The association between multiple sclerosis and early psychiatric background

BACKGROUND

The exact cause of Multiple Sclerosis (MS) is unclear. Since its definition in the late 19th century, researchers have repeatedly suggested a connection between the disease and mental state. Studies have shown that mental symptoms tend to precede the initiation of the disease by up to ten years. However, the hypothesis that psychiatric issues might precede MS onset by longer periods has not been empirically established. This study seeks to fill this research gap. The current matched cohort study investigated the possibility that psychiatric conditions may precede the initiation of multiple sclerosis by 15 years or more METHODS: A retrospective analysis utilizing the electronic database of Clalit Health Services (CHS), Israel's largest HMO, compared a group of 9,533 MS-diagnosed female and male individuals with 28,599 non-MS matched controls RESULTS: Logistic regression analysis revealed a significant association (p < 0.001) between MS diagnosis and prior psychiatric conditions, indicating a 93% increased likelihood of psychiatric history among those later diagnosed with MS compared with those who were not CONCLUSIONS: The heightened probability of mental health issues preceding the onset of MS by extended durations suggests a potential etiological role in the development of MS, rather than solely representing a component of the prodromal stage of the disease. Limitations include the retrospective design and the need for prospective studies to validate these associations.

Brain anomalies in early psychosis: From secondary to primary psychosis

Brain anomalies are frequently found in early psychoses. Although they may remain undetected for many years, their interpretation is critical for differential diagnosis. In secondary psychoses, their identification may allow specific management. They may also shed light on various pathophysiological aspects of primary psychoses. Here we reviewed cases of secondary psychoses associated with brain anomalies, reported over a 20-year period in adolescents and young adults aged 13-30 years old. We considered age at first psychotic symptoms, relevant medical history, the nature of psychiatric symptoms, clinical red flags, the nature of the brain anomaly reported, and the underlying disease. We discuss the relevance of each brain area in light of normal brain function, recent case-control studies, and postulated pathophysiology. We show that anomalies in all regions, whether diffuse, multifocal, or highly localized, may lead to psychosis, without necessarily being associated with non-psychiatric symptoms. This underlines the interest of neuroimaging in the initial workup, and supports the hypothesis of psychosis as a global network dysfunction that involves many different regions.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

Alemtuzumab significantly improves posterior fossa syndrome presented as a relapse of multiple sclerosis

BACKGROUND

Posterior fossa syndrome (PFS) is a rare manifestation of ponto-mesencephalic lesions frequently reported in post-surgical pediatric tumors, rarely described as a consequence of vascular, infective or inflammatory lesions.

OBJECTIVE

The aim of this article is to report the clinical and neuroradiological characteristics of a patient with an acute PFS presentation as a relapse in relapsing-remitting MS, significantly responsive to Alemtuzumab treatment.

CASE REPORT

24-year-old patient affected by multiple sclerosis developed motor-cognitive and behavioral syndrome related to an extensive ponto-mesencephalic lesion under Fingolimod treatment.

CONCLUSION

Our case highlights the significant and rapid effect of Alemtuzumab therapy on both cognitive and motor symptoms occurring during a MS relapse with atypical neuroradiological localization.

Psychiatric Symptoms as the First Clinical Presentation of Multiple Sclerosis: A Case Report

Multiple sclerosis (MS) is an autoimmune condition which affects the axon myelination in the brain. There can be multiple ways it can present initially, but physical signs and symptoms are the most common ones. We are reporting a case of MS from Pakistan which presented with neuropsychiatric features and was offered psychiatric care, but the patient declined treatment because of stigma related to psychiatric care. Four months later when her condition worsened, further investigation showed it to be a case of MS. The purpose of this case report is that psychiatric features should be considered for differentials of MS.

Psychiatric event in multiple sclerosis: could it be the tip of the iceberg?

Multiple sclerosis (MS) is a chronic progressive inflammatory disease of the central nervous system. Psychiatric comorbidities are highly prevalent in patients with MS, and can have drastic impact on quality of life and interpersonal relationships. Despite this high prevalence, whether psychiatric manifestations may represent the first signs of MS is still debatable. This constitutes an important issue, since early diagnosis of "psychiatric-onset MS" would result in prompt management, which usually ameliorates long-term prognosis. Here, we discuss clinical and radiological hints that suggest a diagnosis of psychiatric-onset MS. Briefly, this entity should be considered in healthy patients presenting with late-onset psychiatric symptoms, with or without cognitive decline, and with negative family history of psychiatric diseases. A thorough neurological exam is crucial to detect any subtle neurological signs. Brain magnetic resonance imaging is recommended to rule out frontotemporal lesions that might explain the clinical picture. Poor response to standard psychiatric treatments provides additional evidence for the diagnosis of an organic disease (e.g., MS). Combining psychopharmaceuticals with intravenous corticosteroids would result in good outcomes, but patients should be monitored carefully for possible psychiatric exacerbation, a common side effect of steroids.

Cooccurrences of Putative Endogenous Retrovirus-Associated Diseases

At least 8% of the human genome is composed of endogenous retrovirus (ERV) sequences. ERVs play a role in placental morphogenesis and can sometimes protect the host against exogenous viruses. On the other hand, ERV reactivation has been found to be associated with different diseases, for example, multiple sclerosis (MS), schizophrenia, type 1 diabetes mellitus (T1D), or amyotrophic lateral sclerosis (ALS). Little is known about the cooccurrence of these diseases. If all these diseases are caused by ERV, antiretroviral therapy should perhaps also show some effects in the other diseases. Here, we summarize literature demonstrating that some ERV-associated diseases seem to appear together more often than expected, for example, MS and ALS, MS and T1D, MS and schizophrenia, or ALS and T1D. In contrast, some ERV-associated diseases seem to appear together less frequently than expected, for example, schizophrenia and T1D. Besides, some reports demonstrate amelioration of MS, ALS, or schizophrenia under antiretroviral therapy in human immunodeficiency virus-infected patients. If such results could be confirmed in larger studies, alternative therapy strategies for ERV-associated diseases like MS and schizophrenia might be possible.

Should a psychotic or manic episode be considered an early manifestation of Multiple Sclerosis? A multiple case study

BACKGROUND

Early manifestations of Multiple Sclerosis (MS) can be atypical and misleading, and several case report studies have highlighted that MS onset sometimes takes the form of a psychotic or manic episode.

METHODS

All neurologists belonging to the French Multiple Sclerosis Observatory network were contacted by email and were asked to find patients with MS who presented with a history of psychiatric episode(s) near MS onset.

RESULTS

Seventeen patients were selected that met the criteria of presenting with psychotic or manic symptoms either before the diagnosis of MS (N=8), or at the time of the first neurological episode or shortly after (N=9). Patients with a history of a psychiatric episode occurring before the first neurological episode were diagnosed on average 7 years later than patients with either a first neurological or a mixed (both neurological and psychiatric) episode. However, psychiatric symptoms in the first group and the first neurological symptoms of MS in the second group occurred at a similar age.

CONCLUSION

Based on this multiple case study, we question whether past psychotic or manic episode should be considered equivalent to a first manifestation of MS.

Electroconvulsive therapy in patient with psychotic depression and multiple sclerosis

Safety of electroconvulsive therapy (ECT) in depressive patients with multiple sclerosis (MS) is still discussed and based solely on case reports. This kind of therapy was used in both unipolar depression and depression in bipolar disorder. It was suggested that ECT might cause the deterioration of neurological state (new MS lesions in magnetic resonance imaging). Moreover, there were also data indicating some anesthesiological complications and difficulties in patients with MS. We have presented a case of a patient who was treated with ECT and developed grand mal seizure after 14th electroconvulsive treatment.

Bipolar disorder and multiple sclerosis: a case series

Background. The prevalence of psychiatric disturbance for patients with multiple sclerosis (MS) is higher than that observed in other chronic health conditions. We report three cases of MS and bipolar disorder and we discuss the possible etiological hypothesis and treatment options. Observations. All patients fulfilled the McDonald criteria for MS. Two patients were followed up in psychiatry for manic or depressive symptoms before developing MS. A third patient was diagnosed with MS and developed deferred psychotic symptoms. Some clinical and radiological features are highlighted in our patients: one manic episode induced by high dose corticosteroids and one case of a new orbitofrontal MRI lesion concomitant with the emergence of psychiatric symptoms. All patients needed antipsychotic treatment with almost good tolerance for high dose corticosteroids and interferon beta treatment. Conclusions. MRI lesions suggest the possible implication of local MS-related brain damage in development of pure “psychiatric fits” in MS. Genetic susceptibility is another hypothesis for this association. We have noticed that interferon beta treatments were well tolerated while high dose corticosteroids may induce manic fits.

[Neuropsychiatric manifestations in multiple sclerosis (MS): Might psychotic symptoms signal the onset of the disease?]

Patients suffering from multiple sclerosis (MS) can often dysplay psychiatric symptoms throughout the disease. The frequency of those symptoms could be two or three times greater in MS patients compared to the general population. Psychotic symptoms could be an early sign of MS. At first, neurological symptoms can either be mild or altogether absent. MRI brain scans show cerebral lesions in frontal and temporal regions. New MRI sequencing techniques support the hypothesis that disseminated defects in the grey matter occur in MS. These defects could in turn be responsible for cognitive disorders. Patients presenting a first-episode psychosis must have a neurological examination. MS should be considered as an alternative diagnosis of psychosis, particularly in atypical cases where family history of psychosis is absent and where there is bad response to standard psychotropic treatment. Collaboration between neurologists and psychiatrists whilst caring for patients displaying neuropsychiatric manifestations of MS is crucial to enable more accurate diagnoses and try to improve treatment and overall prognosis.

Neuromyelitis optica, psychiatric symptoms and primary polydipsia: a case report

Neuromyelitis optica (NMO) is an aggressive demyelinating disease that typically affects the optic nerves and spinal cord. While it is increasingly recognized that cerebral lesions are common in NMO, there have been no reported cases of NMO presenting with psychiatric symptoms and polydipsia. We describe a patient with classic signs and symptoms of NMO who also demonstrated prominent psychiatric symptoms and polydipsia that were tied to his flares and resolved with treatment of his NMO. This case expands our understanding of possible presentations of NMO.

Psychotic features associated with multiple sclerosis

Although once considered rare, several more recent investigations have been published describing psychotic features in multiple sclerosis (MS). The association between the two conditions, however, remains unclear. Large-scale hospital-based, epidemiological and case studies have suggested a relationship between psychosis and MS through demonstrating their higher than chance co-occurrence, their temporal relationship, and their association with particular structural abnormalities in the brain (i.e., periventricular white matter and temporal demyelination). The etiology of psychosis in MS has also not been explained adequately. Regional demyelination and the use of corticosteroids have been implicated, yet their mechanisms of action have not been elucidated. The present review addresses what is known at this point in time regarding the occurrence of psychosis in the context of MS, the data regarding possible etiological factors, and the implications of these data and suggestions regarding diagnosis and treatment. Future research should explore the underlying pathophysiology of psychosis and multiple sclerosis to further our understanding of the central nervous system disease process. This research could help determine the features which would guide clinicians in identifying patients at risk of developing psychosis in the context of MS, as well as propose the optimal pharmacological intervention.

Outcome of psychiatric symptoms presenting at onset of multiple sclerosis: a retrospective study

Psychiatric disturbances may occur at the onset of multiple sclerosis. However, information on their outcome is lacking. Our objective was to document the characteristics of psychiatric symptoms at presentation of multiple sclerosis and to define the long-term evolution of psychiatric disturbances in these patients. Based on a clinical record analysis of patients with defined multiple sclerosis diagnosis and coming under the care of a university multiple sclerosis centre within the period 1997-2007, patients with both psychiatric and neurological symptoms at presentation were identified. Clinical data at onset and at last follow-up were considered. Among 682 evaluated patients, psychiatric disturbances were associated with multiple sclerosis onset in 16 cases (2.3%). Most patients (56%) presented with a mood disorder with clinical characteristics of a major depressive-like episode, five (32%) had psychotic symptoms. Initial psychiatric disturbances improved later than neurological symptoms, or never fully recovered, regardless of the concomitant use of psychotropic medications. In most of the subjects psychiatric disturbances tended to remain over the follow-up period and at last visit, after a mean follow-up of 7.6 years (+/-2.3), 14 subjects (87%) had a supplementary diagnosis of psychiatric illness. Psychiatric symptoms at onset of multiple sclerosis may be indicators of possible maintenance of psychiatric morbidity in a sizeable proportion of patients.

Psychiatric disorders in multiple sclerosis patients

Multiple sclerosis (MS) is a demyelinating disease showing variable clinical presentation. Optic neuritis is the most common symptom, followed by motor and sensitive manifestations. It is known that this disease may be related to several psychiatric disorders, especially depression. In this study we will discribe 5 cases of MS patients harboring psychiatric disorder related or unchained by the disease itself.

Psychopathology in multiple sclerosis: diagnosis, prevalence and treatment

Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system. Demyelinization of nerve fibres not only affects the motor and sensory systems functionally, but may also cause psychopathological signs and symptoms. In addition to the psychiatric manifestations of MS, many patients have reactive psychological problems that are often hard to distinguish from the 'organic' causation of psychopathology. In any event, psychiatric comorbidity in MS deserves greater clinical attention than has been previously paid, because the presence of psychopathology may have deleterious effects on the disease process and impair coping with disability.

Bipolar disorder and multiple sclerosis

Bipolar disorder may be overrepresented in multiple sclerosis (MS) patients. Although research in this area is limited, studies assessing the nature of this association have focused on genetic aspects, adverse reaction to drugs and brain demyelinating lesions. Herein we report three patients with MS that also presented bipolar disorder. The coexistence of neurological and psychiatric symptoms in most MS relapses highlights the relevance of biological factors in the emergence of mood disorders in these patients.

Case report: "Purely" psychiatric presentation of multiple sclerosis in an adolescent boy

We present the case of a 14-year-old Hispanic boy with a 6-month history of a psychotic disorder necessitating several hospitalizations who was incidentally found to have multiple sclerosis with no physical findings. Neuropsychological assessment has revealed impairments in word-finding, bilateral fine motor skills, and attention. Imaging and laboratory studies have supported the diagnosis of multiple sclerosis. Steroid and immunomodulating therapy has not significantly affected psychiatric symptoms. He has had poor response to psychotropic medications as well. We discuss the implications of multiple sclerosis as the cause of this patient's psychiatric illness.

Perioperative care of patients with neuromuscular disease and dysfunction

A variety of different pathologies result in disease phenotypes that are summarized as neuromuscular diseases because they share commonalty in their clinical consequences for the patient: a progressive weakening of the skeletal muscles. Distinct caution and appropriate changes to the anesthetic plan are advised when care is provided during the perioperative period. The choice of anesthetic technique, anesthetic drugs, and neuromuscular blockade always depends on the type of neuromuscular disease and the surgical procedure planned. A clear diagnosis of the underlying disease and sufficient knowledge and understanding of the pathophysiology are of paramount importance to the practitioner and guide optimal perioperative management of affected patients.