The differential diagnosis of multiple sclerosis and bipolar disorder

Manic episode in patient with bipolar disorder and recent multiple sclerosis diagnosis: A case report

INTRODUCTION/RATIONALE

Multiple sclerosis (MS) is associated with a higher prevalence of mood and psychiatric disorders, such as bipolar disorder (BD). While mania is most often associated with BD, MS can also induce manic symptoms. However, it is crucial to distinguish which condition is causing mania since medical management is different based on its etiology. Herein, we report a case of a manic episode in a middle-aged female with a prolonged history of BD who received a recent diagnosis of MS 1 year ago.

PATIENT CONCERNS

A 56-year-old female presented with an episode of mania and psychosis while receiving a phenobarbital taper for chronic lorazepam use. She had a prolonged history of bipolar type 1 disorder and depression. She showed optic neuritis and was diagnosed with MS a year prior.

DIAGNOSES

The patient was diagnosed with BD-induced mania based on the absence of increased demyelination compared to previous MRI and lack of new focal or lateralizing neurologic findings of MS.

INTERVENTIONS

Lithium was given for mood stabilization and decreased dosage of prior antidepressant medication. Risperidone was given for ongoing delusions.

OUTCOMES

After 8 days of hospitalization, patient's mania improved but demonstrated atypical features and ongoing delusions. She was discharged at her request to continue treatment in an outpatient setting.

CONCLUSION/LESSON

In BD patients with an episode of mania, MS should be included in the differential, since both conditions can cause manic symptoms. The origin of mania should be delineated through a detailed neurological exam, neuroimaging, and thorough patient-family psychiatric history for appropriate clinical treatment.

The neuropsychiatry of multiple sclerosis

Multiple sclerosis is the most common disabling neurological illness affecting young and middle-aged adults. Although attention has tended to focus mainly on its neurological manifestations, reports of the presence of neuropsychiatric symptoms date back to the writings of Charcot in 1877. This article details the neuropsychiatric sequelae of multiple sclerosis and the evidence base for available treatments.

Bipolar disorder and resembling special psychopathological manifestations in multiple sclerosis: a review

PURPOSE OF REVIEW

The higher prevalence of psychiatric disorders in multiple sclerosis (MS) compared with the general population is well documented, with depression being the leading disorder. Apart from depression, other psychiatric disorders and symptoms such as bipolar disorder, pseudobulbar affect, euphoria sclerotica, anxiety and personality changes are also reported to be overpresented in MS patients. Psychiatric disorders in MS lead to significant disruption in patients' family, work and social life, affecting patients' quality of life in general. Moreover, they are reported to be associated with poorer adherence to MS medication. The literature concerning bipolar disorder and affect disorders in MS is rather scarce. The purpose of this article is to provide a critical review on the latter subject.

RECENT FINDINGS

This review focuses upon the recent findings with regard to the epidemiology and the comorbidity rates of bipolar and affect disorders in MS, questions raised about the potential underlying mechanisms that could explain such a high comorbidity, diagnostic issues and the recent developments in the treatment of those psychiatric disorders in MS.

SUMMARY

Despite the fact that the higher prevalence of psychiatric disorders in MS is well established, such disorders still remain underdiagnosed and undertreated. A shift in the clinical suspicion towards the psychiatric morbidity in MS patients and the optimal treatment of those disorders is fundamental.

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.

Familial bipolar disorder and multiple sclerosis: a three-generation HLA family study

The coexistence of bipolar disorder (BD) and multiple sclerosis (MS) is well known. Manic symptoms may represent initial symptoms of MS, at least in some cases, and follow the MS-HLA phenotype frequencies. The purpose of this study was to examine the possible relation of BD and MS based on an HLA family study of a woman with BD and comorbid MS, with family history of BD. Five members of the family from three generations (the patient, her mother, her brother, and her two daughters) were examined regarding the two disorders and the HLA class I and II specificities, performed by serology and molecular techniques. Her deceased father, her brother, and her older daughter suffered from BD. Moreover, in her brother, BD and MS comorbidity was diagnosed. The three affected members and the nonaffected grandmother share the same class I and II, HLA-A2, B18, CW8, DR2, DQ1 haplotype. The shared class II, HLA-DR2, DQ1 haplotype among affected individuals, which is well known to be associated with MS in Caucasians, suggests a possible susceptibility locus for BD, mapped on chromosome 6, very close to the HLA region, underlying the clinical comorbidity of the two disorders.

Bipolar Disorder in Neurologic Illness

Patients with neurologic illness frequently develop secondary mood disorders that are broadly categorized as unipolar or bipolar illnesses. Although depressive disorders are more commonly seen in neurologic patients, bipolar illnesses can be as debilitating and more difficult to treat. Distinguishing between primary manias (ie, no known brain injury) and secondary manias (ie, etiologically linked to a disease) is important, because secondary manias may present with different symptoms and require different treatments from primary manias. Aggressive treatment of mania improves quality of life, reduces morbidity and mortality, and may prevent worsening of both psychiatric and neurologic disease. Bipolar disorder associated with neurologic illness typically requires treatment with mood stabilizers such as lithium, divalproex sodium, or carbamazepine. A number of other pharmacologic treatments are emerging, many of them using antiepileptic drugs that may have dual use in neurologic patients. Although psychotherapy in combination with medication improves outcome in bipolar illness, psychotherapy alone is not effective for this condition. Treatment of bipolar disorder, especially in the depressed phase, is complicated, and should be referred to a psychiatrist.