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1
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Vesic K, Gavrilovic A, Mijailović NR, Borovcanin MM. Neuroimmune, clinical and treatment challenges in multiple sclerosis-related psychoses. World J Psychiatry 2023; 13:161-170. [PMID: 37123101 PMCID: PMC10130959 DOI: 10.5498/wjp.v13.i4.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/16/2023] [Accepted: 03/23/2023] [Indexed: 04/18/2023] Open
Abstract
In recent years, epidemiological and genetic studies have shown an association between autoimmune diseases and psychosis. The question arises whether patients with schizophrenia are more likely to develop multiple sclerosis (MS) later in life. It is well known that the immune system plays an important role in the etiopathogenesis of both disorders. Immune disturbances may be similar or very different in terms of different types of immune responses, disturbed myelination, and/or immunogenetic predispositions. A psychotic symptom may be a consequence of the MS diagnosis itself or a separate entity. In this review article, we discussed the timing of onset of psychotic symptoms and MS and whether the use of corticosteroids as therapy for acute relapses in MS is unfairly neglected in patients with psychiatric comorbidities. In addition, we discussed that the anti-inflammatory potential of antipsychotics could be useful and should be considered, especially in the treatment of psychosis that coexists with MS. Autoimmune disorders could precipitate psychotic symptoms, and in this context, autoimmune psychosis must be considered as a persistent symptomatology that requires continuous and specific treatment.
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Affiliation(s)
- Katarina Vesic
- Department of Neurology, University of Kragujevac, Faculty of Medical Sciences, Kragujevac 34000, Sumadija, Serbia
| | - Aleksandar Gavrilovic
- Department of Neurology, University of Kragujevac, Faculty of Medical Sciences, Kragujevac 34000, Sumadija, Serbia
| | - Nataša R Mijailović
- Department of Pharmacy, University of Kragujevac, Faculty of Medical Sciences, Kragujevac 34000, Sumadija, Serbia
| | - Milica M Borovcanin
- Department of Psychiatry, University of Kragujevac, Faculty of Medical Sciences, Kragujevac 34000, Sumadija, Serbia
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2
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Sabe M, Sentissi O. Psychotic symptoms prior or concomitant to diagnosis of multiple sclerosis: a systematic review of case reports and case series. Int J Psychiatry Clin Pract 2022; 26:287-293. [PMID: 34487465 DOI: 10.1080/13651501.2021.1973506] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to examine the clinical features of psychotic symptoms preceding or concomitant to multiple sclerosis (MS) diagnosis. METHOD From the 1st to 10th of January 2020 a systematic review was conducted through an electronic search of different databases. Results were limited to English, French, German, Italian and Spanish language articles. RESULTS We identified 599 titles, and included 32 cases from case-report and case series. One case report from our department was added. The mean age of first psychiatric symptoms was 25.8 ± 10.2 years, the mean age of MS diagnosis was 31.2 ± 10.7 years and the mean delay until MS diagnosis was 2.7 ± 3 years. Most reported symptoms were delusions (81%), auditory hallucinations (59%) and visual hallucinations (50%). Upon the MS diagnosis, immunosuppressive therapy was significantly more effective for psychotic symptoms than antipsychotics (OR = 9.0; 95%CI: 2.15-37; p = 0.002). Diffuse periventricular lesions were found in 95.6% of cases, with mostly temporal or frontal predominant lesions. In cases affected by predominant temporal lesions, 83% of cases presented visual hallucinations (p < 0.05). CONCLUSION Poor response or resistance to antipsychotics treatment should alert clinicians on the need to consider a differential diagnosis. Considering the impact of delay in MS diagnosis further research regarding this subject is warranted.KEY POINTSInsight into the occurrence of psychotic symptoms in multiple sclerosis (MS) is mainly limited to case reports and case series.Delay in MS management between initial psychotic symptoms and the MS diagnosis is 2.73 ± 3 years and 0.8 ± 1.2 years for patients presenting a first episode of psychosis.The resistance and poor response to antipsychotics found in most cases (75%) were associated with an excellent improvement (95%) of both psychiatric and neurologic symptoms with corticosteroids.Prospective studies are needed to investigate the spectrum of psychosis in MS.
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Affiliation(s)
- Michel Sabe
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Thonex, Switzerland
| | - Othman Sentissi
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, Thonex, Switzerland
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3
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Lee TY, Jo HJ. Differential diagnosis and comorbid physical illness of schizophrenia. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2021. [DOI: 10.5124/jkma.2021.64.8.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Schizophrenia is a neurodevelopmental disorder that generally develops during adolescence or early adulthood. However, differentiating it from psychosis caused by a physical illness is difficult due to the phenotypebased diagnostic system. In this review, differential diagnosis of schizophrenia and the comorbid physical illnesses of patients with schizophrenia will be discussed.Current Concepts: Psychotic symptoms can be caused by various physical illnesses, and patients with schizophrenia have many physical comorbidities. Symptoms of psychosis can also be expressed by physical illness including brain tumors, encephalitis, temporal lobe epilepsy, autoimmune disease, and genetic disease. For the differential diagnosis of other physical illnesses that can cause psychosis, biological tests are essential. Depending on the cause, antipsychotics and treatment of physical diseases are required. In addition, patients with schizophrenia have many comorbid medical conditions such as obesity, diabetes, cardiovascular disease, but the diagnosis rate is low, and the mortality is higher than that of the general population due to untreated medical diseases.Discussion and Conclusion: The differential diagnoses of schizophrenia and physical illness causing psychosis are important. To decrease the high mortality of patients with schizophrenia, periodic physical condition examinations and mental status examinations should be conducted.
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4
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Bae KY, Kang HJ, Kim JW, Kim SW, Kim JT, Park MS, Cho KH, Kim JM. Associations of white matter hyperintensities with poststroke depression: A 1-year longitudinal study. Int J Geriatr Psychiatry 2019; 34:162-168. [PMID: 30251444 DOI: 10.1002/gps.5005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/03/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Depression is common in stroke survivors and may lead to a poor prognosis and more severe functional impairment. Although subcortical white matter hyperintensities (WMHs) are associated with late-life depression, few studies have examined the association between depression and WMHs after a stroke. We investigated the associations of periventricular (PVWMH) and deep (DWMH) WMHs with poststroke depression (PSD) at two time points after stroke. METHODS A total of 408 patients were evaluated 2 weeks after stroke (baseline), and of those, 284 (70%) were followed up 1 year later. Magnetic resonance images were obtained in all subjects at baseline. PVWMHs and DWMHs were rated using the four-point modified Fazekas scale and categorized as mild (grades 0 and 1) or severe (grades 2 and 3). Depression was diagnosed according to DSM-IV criteria, and subjects were divided into without PSD, any PSD, and major PSD groups at baseline, and follow-up examinations were conducted according to the severity of depression. Associations of PSD with PVWMHs and DWMHs were assessed using multivariate logistic regression analyses after adjusting for various demographic and clinical characteristics. RESULTS The adjusted analyses revealed that severe PVWMHs were significantly associated with any PSD at baseline and severe DWMHs were significantly associated with major PSD at follow-up. CONCLUSION The association between WMH and PSD varies according to type of WMH, and time after stroke, such that early depressive symptoms are associated with PVWMHs, and delayed severe depression is associated with DWMHs.
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Affiliation(s)
- Kyung-Yeol Bae
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hee-Ju Kang
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ju-Wan Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Sung-Wan Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jae-Min Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
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5
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Yakushina TI, Belova YA. [Psychotic disorders in multiple sclerosis]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:110-115. [PMID: 30160678 DOI: 10.17116/jnevro2018118082110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nowadays there is no definite answer to questions: either multiple sclerosis (MS) patients with psychotic disorders have two independent diseases (multiple sclerosis and schizophrenia) or psychotic episodes are associated with organic damage of brain substances. The authors describe two cases of patients with MS with psychotic disorders which could help to clarify the problem.
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Affiliation(s)
- T I Yakushina
- Vladimirskiy Moscow Regional Research Clinical Institute, Moscow, Russia
| | - Yu A Belova
- Vladimirskiy Moscow Regional Research Clinical Institute, Moscow, Russia
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Chalah MA, Ayache SS. Psychiatric event in multiple sclerosis: could it be the tip of the iceberg? ACTA ACUST UNITED AC 2017; 39:365-368. [PMID: 28355344 PMCID: PMC7111399 DOI: 10.1590/1516-4446-2016-2105] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 11/23/2016] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Moussa A Chalah
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France.,Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Samar S Ayache
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France.,Service de Physiologie - Explorations Fonctionnelles, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France.,Neurology Division, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
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7
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The varieties of psychosis in multiple sclerosis: A systematic review of cases. Mult Scler Relat Disord 2017; 12:9-14. [DOI: 10.1016/j.msard.2016.12.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/21/2016] [Accepted: 12/23/2016] [Indexed: 11/30/2022]
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Gilberthorpe TG, O'Connell KE, Carolan A, Silber E, Brex PA, Sibtain NA, David AS. The spectrum of psychosis in multiple sclerosis: a clinical case series. Neuropsychiatr Dis Treat 2017; 13:303-318. [PMID: 28203081 PMCID: PMC5295796 DOI: 10.2147/ndt.s116772] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Psychosis in the context of multiple sclerosis (MS) has previously been reported as a rare occurrence. However, recent epidemiological studies have found prevalence rates of psychosis in MS that are two to three times higher than those in the general population. Untreated psychosis in patients with MS can adversely impact on adherence to MS medication, levels of disability, and quality of life. This retrospective case series describes the spectrum of psychotic disorders occurring in association with MS using demographic, clinical, and neuroimaging data. In the discussion, we highlight the particular diagnostic and treatment challenges that such disorders can pose for clinicians and through our case vignettes provide examples of potential interventions for this complex patient population.
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Affiliation(s)
- Thomas G Gilberthorpe
- Department of Liaison Psychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
| | - Kara E O'Connell
- Department of Psychiatry, School of Medicine, Trinity College Dublin, Ireland; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience
| | - Alison Carolan
- Department of Liaison Psychiatry, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, UK
| | - Eli Silber
- Department of Neurology, Kings College Hospital, London, UK
| | - Peter A Brex
- Department of Neurology, Kings College Hospital, London, UK
| | | | - Anthony S David
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience
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9
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Should a psychotic or manic episode be considered an early manifestation of Multiple Sclerosis? A multiple case study. Mult Scler Relat Disord 2016; 6:93-96. [PMID: 27063631 DOI: 10.1016/j.msard.2016.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/03/2016] [Accepted: 02/06/2016] [Indexed: 01/12/2023]
Abstract
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.
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10
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Bipolar disorder and multiple sclerosis: a case series. Behav Neurol 2014; 2014:536503. [PMID: 24825960 PMCID: PMC4006599 DOI: 10.1155/2014/536503] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 07/21/2013] [Indexed: 11/26/2022] Open
Abstract
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.
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11
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Granberg T, Martola J, Aspelin P, Kristoffersen-Wiberg M, Fredrikson S. Radiologically isolated syndrome: an uncommon finding at a university clinic in a high-prevalence region for multiple sclerosis. BMJ Open 2013; 3:e003531. [PMID: 24189079 PMCID: PMC3822304 DOI: 10.1136/bmjopen-2013-003531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The improved availability of MRI in medicine has led to an increase in incidental findings. Unexpected brain MRI findings suggestive of multiple sclerosis (MS) without typical symptoms of MS were recently defined as radiologically isolated syndrome (RIS). The prevalence of RIS is uncertain. The aim of this study was to determine the prevalence of RIS at a university hospital in a region with a high prevalence for MS and describe the long-term prognosis of the identified patients. DESIGN Retrospective cohort study conducted in 2012. SETTING All brain MRI examinations performed at Karolinska University Hospital in Huddinge, Stockholm, Sweden during 2001 were retrospectively screened by a single rater for findings fulfilling the Okuda criteria. The sample year was chosen in order to establish the long-term prognosis of the patients identified. The examinations of interest were re-evaluated according to the Barkhof criteria by a neuroradiologist with long experience in MS. PARTICIPANTS In total 2105 individuals were included in the study. Ages ranged from 0 to 90 years with a median age of 48 years. Only one patient with RIS was identified, equivalent to a prevalence of 0.05% in the studied population, or 0.15% among patients aged 15-40 years. The patient with RIS developed symptoms consistent with MS within 3 months accompanied with radiological progression and was diagnosed with MS. CONCLUSIONS RIS, according to present criteria, is an uncommon finding in a tertiary hospital setting in a high-prevalence region for MS where awareness and clinical suspicion of MS is common. In order to study the prognosis of RIS, multicentre studies, or case-control studies are recommended.
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Affiliation(s)
- Tobias Granberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Juha Martola
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Peter Aspelin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | | | - Sten Fredrikson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Morphostructural MRI abnormalities related to neuropsychiatric disorders associated to multiple sclerosis. Mult Scler Int 2013; 2013:102454. [PMID: 23691320 PMCID: PMC3654321 DOI: 10.1155/2013/102454] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 03/27/2013] [Indexed: 11/17/2022] Open
Abstract
Multiple Sclerosis associated neuropsychiatric disorders include major depression (MD), obsessive-compulsive disorder (OCD), bipolar affective disorder, euphoria, pseudobulbar affect, psychosis, and personality change. Magnetic Resonance Imaging (MRI) studies focused mainly on identifying morphostructural correlates of MD; only a few anecdotal cases on OCD associated to MS (OCD-MS), euphoria, pseudobulbar affect, psychosis, personality change, and one research article on MRI abnormalities in OCD-MS have been published. Therefore, in the present review we will report mainly on neuroimaging abnormalities found in MS patients with MD and OCD. All together, the studies on MD associated to MS suggest that, in this disease, depression is linked to a damage involving mainly frontotemporal regions either with discrete lesions (with those visible in T1 weighted images playing a more significant role) or subtle normal appearing white matter abnormalities. Hippocampal atrophy, as well, seems to be involved in MS related depression. It is conceivable that grey matter pathology (i.e., global and regional atrophy, cortical lesions), which occurs early in the course of disease, may involve several areas including the dorsolateral prefrontal cortex, the orbitofrontal cortex, and the anterior cingulate cortex whose disruption is currently thought to explain late-life depression. Further MRI studies are necessary to better elucidate OCD pathogenesis in MS.
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13
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[Neuropsychiatric manifestations in multiple sclerosis (MS): Might psychotic symptoms signal the onset of the disease?]. Presse Med 2013; 42:1186-95. [PMID: 23582147 DOI: 10.1016/j.lpm.2012.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 10/11/2012] [Indexed: 11/22/2022] Open
Abstract
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.
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Bourdette D, Yadav V. Treat patients with radiologically isolated syndrome when the MRI brain scan shows dissemination in time: No. Mult Scler 2012; 18:1529-30. [PMID: 23100523 DOI: 10.1177/1352458512462075] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dennis Bourdette
- Department of Neurology, Oregon Health and Science University and MS Center of Excellence-West/Portland Veterans Affairs Medical Center, USA
- Department of Neurology, Oregon Health and Science University and MS Center of Excellence-West, USA
| | - Vijayshree Yadav
- Department of Neurology, Oregon Health and Science University and MS Center of Excellence-West/Portland Veterans Affairs Medical Center, USA
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Granberg T, Martola J, Kristoffersen-Wiberg M, Aspelin P, Fredrikson S. Radiologically isolated syndrome--incidental magnetic resonance imaging findings suggestive of multiple sclerosis, a systematic review. Mult Scler 2012; 19:271-80. [PMID: 22760099 DOI: 10.1177/1352458512451943] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With increasing availability of magnetic resonance imaging (MRI), there is also an increase in incidental abnormal findings. MRI findings suggestive of multiple sclerosis in persons without typical multiple sclerosis symptoms and with normal neurological findings are defined as radiologically isolated syndrome (RIS). Half of the persons with RIS have their initial MRI because of headache, and some have a subclinical cognitive impairment similar to that seen in multiple sclerosis. Radiological measurements also show a similarity between RIS and multiple sclerosis. Approximately two-thirds of persons with RIS show radiological progression and one-third develop neurological symptoms during mean follow-up times of up to five years. Cervical cord lesions are important predictors of clinical conversion. Management has to be individualised, but initiation of disease modifying therapy is controversial and not recommended outside of clinical trials since its effects have not been studied in RIS. Future studies should try to establish the prevalence and long-term prognosis of RIS, its impact on quality of life, and define the role of disease modifying therapy in RIS.
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Affiliation(s)
- Tobias Granberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Sweden.
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16
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Lana-Peixoto MA. How much radiologically isolated syndrome suggestive of multiple sclerosis is multiple sclerosis? ARQUIVOS DE NEURO-PSIQUIATRIA 2012; 70:2-4. [PMID: 22218465 DOI: 10.1590/s0004-282x2012000100002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cerqueira ACRD, Nardi AE, Souza-Lima F, Godoy-Barreiros JM. Bipolar disorder and multiple sclerosis: comorbidity and risk factors. BRAZILIAN JOURNAL OF PSYCHIATRY 2011; 32:454-6. [PMID: 21308269 DOI: 10.1590/s1516-44462010000400021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Spain R, Bourdette D. The Radiologically Isolated Syndrome: Look (Again) Before You Treat. Curr Neurol Neurosci Rep 2011; 11:498-506. [DOI: 10.1007/s11910-011-0213-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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De Stefano N, Stromillo ML, Rossi F, Battaglini M, Giorgio A, Portaccio E, Hakiki B, Malentacchi G, Gasperini C, Santangelo M, Bartolozzi ML, Sormani MP, Federico A, Amato MP. Improving the characterization of radiologically isolated syndrome suggestive of multiple sclerosis. PLoS One 2011; 6:e19452. [PMID: 21559385 PMCID: PMC3084867 DOI: 10.1371/journal.pone.0019452] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/29/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To improve the characterization of asymptomatic subjects with brain magnetic resonance imaging (MRI) abnormalities highly suggestive of multiple sclerosis (MS), a condition named as "radiologically isolated syndrome" (RIS). METHODS Quantitative MRI metrics such as brain volumes and magnetization transfer (MT) were assessed in 19 subjects previously classified as RIS, 20 demographically-matched relapsing-remitting MS (RRMS) patients and 20 healthy controls (HC). Specific measures were: white matter (WM) lesion volumes (LV), total and regional brain volumes, and MT ratio (MTr) in lesions, normal-appearing WM (NAWM) and cortex. RESULTS LV was similar in RIS and RRMS, without differences in distribution and frequency at lesion mapping. Brain volumes were similarly lower in RRMS and RIS than in HC (p<0.001). Lesional-MTr was lower in RRMS than in RIS (p = 0.048); NAWM-MTr and cortical-MTr were similar in RIS and HC and lower (p<0.01) in RRMS. These values were particularly lower in RRMS than in RIS in the sensorimotor and memory networks. A multivariate logistic regression analysis showed that 13/19 RIS had ≥70% probability of being classified as RRMS on the basis of their brain volume and lesional-MTr values. CONCLUSIONS Macroscopic brain damage was similar in RIS and RRMS. However, the subtle tissue damage detected by MTr was milder in RIS than in RRMS in clinically relevant brain regions, suggesting an explanation for the lack of clinical manifestations of subjects with RIS. This new approach could be useful for narrowing down the RIS individuals with a high risk of progression to MS.
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Affiliation(s)
- Nicola De Stefano
- Department of Neurological and Behavioral Sciences, University of Siena, Siena, Italy.
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Okuda DT, Mowry EM, Cree BAC, Crabtree EC, Goodin DS, Waubant E, Pelletier D. Asymptomatic spinal cord lesions predict disease progression in radiologically isolated syndrome. Neurology 2011; 76:686-92. [PMID: 21270417 DOI: 10.1212/wnl.0b013e31820d8b1d] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Technological advancements in neuroimaging and the increased use of these diagnostic modalities are responsible for the discovery of incidentally identified anomalies within the CNS. In addition to the identification of unanticipated brain MRI abnormalities suggestive of demyelinating disease in patients undergoing neuroimaging for a medical reason other than evaluation for multiple sclerosis (MS), asymptomatic spinal cord lesions are periodically identified. OBJECTIVE To determine if asymptomatic spinal cord lesions are associated with clinical progression in subjects with radiologically isolated syndrome (RIS). METHODS A retrospective review of RIS cases at the University of California, San Francisco Multiple Sclerosis Center was performed. The presence of asymptomatic cervical spinal cord MRI lesions was analyzed as a potential predictor for clinical progression. RESULTS Twenty-five of 71 subjects with RIS possessed findings within the cervical spine that were highly suggestive of demyelinating disease. Of these subjects, 21 (84%) progressed clinically to clinically isolated syndrome (n = 19) or primary progressive multiple sclerosis (n = 2) over a median time of 1.6 years from the date of RIS identification (interquartile range 0.8-3.8). The sensitivity, specificity, and positive predictive value of an asymptomatic spinal cord lesion for subsequent development of either a first demyelinating attack or primary progressive MS were 87.5%, 91.5%, and 84%, respectively. The odds ratio of clinical progression was 75.3 (95% confidence interval 16.1-350.0, p < 0.0001). This association remained significant after adjusting for potential confounders. CONCLUSION These findings suggest that the presence of asymptomatic spinal cord lesions place subjects with RIS at substantial risk for clinical conversion to either an acute or progressive event, a risk that is independent of brain lesions on MRI.
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Affiliation(s)
- D T Okuda
- Department of Neurology, UCSF Multiple Sclerosis Center, University of California, San Francisco, San Francisco, USA.
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21
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Kosmidis MH, Giannakou M, Messinis L, Papathanasopoulos P. Psychotic features associated with multiple sclerosis. Int Rev Psychiatry 2010; 22:55-66. [PMID: 20233114 DOI: 10.3109/09540261003589612] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Mary H Kosmidis
- School of Psychology, Aristotle University of Thessaloniki, GR54124Thessaloniki, Greece.
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22
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The radiologically isolated syndrome: take action when the unexpected is uncovered? J Neurol 2010; 257:1602-11. [PMID: 20503053 DOI: 10.1007/s00415-010-5601-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 05/08/2010] [Accepted: 05/11/2010] [Indexed: 11/27/2022]
Abstract
The increasing diagnostic application of magnetic resonance imaging (MRI) in neurology has resulted in an increase in accidental disclosure of asymptomatic brain pathologies with potential clinical significance. Here, we discuss the incidental detection of multiple sclerosis (MS) typical central nervous system (CNS) lesions fulfilling MRI criteria for dissemination in space (radiologically isolated syndrome, RIS) and its diagnostic, prognostic and therapeutic implications. Three recent studies, including a total of 136 RIS cases which were followed for up to 10 years, indicate that a subgroup of such patients will develop MS. MRI-based dissemination in time (DIT) was determined in more than two-thirds and clinically isolated syndrome (CIS) occurred in almost one-third of the patients. Presence of Gadolinium (Gd)-enhancing lesions was identified as potential predictor for MRI-based DIT in one study, and pathological visual evoked potential (VEP) examinations at baseline and Gd-enhancement at the second MRI scan for CIS (clinical DIT) in another study. In the lack of established management guidelines, we propose a pragmatic diagnostic and therapeutic approach for patients with RIS. Individual concepts are required and both "wait" as well as "follow" strategies are justifiable. Further prospective studies are required to elucidate potential biomarkers for narrowing down the high-risk cohort and exploring further characteristics of this disease stage.
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Bae S, Kim JE, Hwang J, Lee YS, Lee HH, Lee J, Lyoo IK, Renshaw PF, Yoon SJ. Increased prevalence of white matter hyperintensities in patients with panic disorder. J Psychopharmacol 2010; 24:717-23. [PMID: 18957476 DOI: 10.1177/0269881108098476] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of the current study is to compare the prevalence, severity and location of cerebral white matter hyperintensities (WMH) between patients with panic disorder (PD) and healthy control subjects. Patients with PD (n = 24) and matched healthy control subjects (n = 24) were scanned using a 3.0 Tesla whole-body magnetic resonance scanner. Axial T2-weighted and fluid-attenuated inversion recovery images were acquired and evaluated for the prevalence, severity and location of WMH using the modified composite scale of Fazekas and Coffey and coded separately for deep and periventricular WMH. Logistic regression analyses were used to assess the association between WMH and the diagnosis of PD. A greater severity of total WMH was associated with a diagnosis of PD in a dose-dependent pattern (odds ratio [OR] = 8.8, P = 0.005 for mild WMH; OR = 27.7, P = 0.007 for moderate to severe WMH). Deep WMH, where most group differences originated, were predominantly located in the frontal region of the brain (n = 16 in PD, n = 1 in control). The current report is the first study to report an increased prevalence of WMH in patients with PD.
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Affiliation(s)
- S Bae
- Department of Psychiatry, Seoul National University and Hospital, Seoul, South Korea
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24
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[Radiologically isolated syndrome: multiple sclerosis based solely on MRI findings?]. DER NERVENARZT 2010; 81:1208-17. [PMID: 20422146 DOI: 10.1007/s00115-010-2998-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Incidental brain magnetic resonance imaging (MRI) findings are the result of an increasing usage of MRI in the diagnostic work-up of patients. An adequate assessment of patients in which brain lesions typical for multiple sclerosis (MS) are determined but who have been asymptomatic so far is problematic, especially when Barkhof-Tintoré criteria for spatial dissemination are fulfilled and no other differential diagnosis can be confirmed. This entity, the so-called radiologically isolated syndrome, constitutes a major diagnostic and therapeutic challenge. Two recent studies revealed that a subgroup of patients with radiologically isolated syndrome are at high risk for near-term development of MR-based progression and occurrence of the first clinical event. Hence, the radiologically isolated syndrome has to be classified as a possible preliminary phase of the clinical manifestation of MS in a subgroup of patients and entails in-depth therapeutic considerations. This article covers the current literature for this syndrome and, in the absence of official guidelines, provides a pragmatic diagnostic and therapeutic approach for patient management.
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Lo Fermo S, Barone R, Patti F, Laisa P, Cavallaro TL, Nicoletti A, Zappia M. Outcome of psychiatric symptoms presenting at onset of multiple sclerosis: a retrospective study. Mult Scler 2010; 16:742-8. [PMID: 20350959 DOI: 10.1177/1352458510365157] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Blanc F, Berna F, Fleury M, Lita L, Ruppert E, Ferriby D, Vermersch P, Vidailhet P, de Seze J. Évènements psychotiques inauguraux de sclérose en plaques ? Rev Neurol (Paris) 2010; 166:39-48. [DOI: 10.1016/j.neurol.2009.04.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2008] [Revised: 04/20/2009] [Accepted: 04/26/2009] [Indexed: 01/21/2023]
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Siva A, Saip S, Altintas A, Jacob A, Keegan BM, Kantarci OH. Multiple sclerosis risk in radiologically uncovered asymptomatic possible inflammatory-demyelinating disease. Mult Scler 2009; 15:918-27. [PMID: 19667020 DOI: 10.1177/1352458509106214] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Natural history of patients with incidentally discovered lesions that fulfill magnetic resonance imaging (MRI) criteria for multiple sclerosis (MS) in the absence of objective clinical symptoms suggestive of central nervous system (CNS) inflammatory-demyelinating disease is not well defined. OBJECTIVE We evaluated the risk of developing symptomatic MS in patients with radiologically uncovered asymptomatic possible inflammatory-demyelinating disease (RAPIDD). METHODS We identified and longitudinally followed a cohort of 22 patients from two tertiary care MS centers: Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey, and Mayo Clinic, Rochester, Minnesota, after an initial MRI study fulfilling the Barkhof-Tintore MRI criteria completed for other reasons unrelated to MS. RESULTS Eight of 22 patients developed an objective clinical symptom consistent with a CNS inflammatory-demyelinating syndrome and fulfilled dissemination in space and time criteria for definite MS. Median age at the time of diagnosis of MS was 44.8 years (range 28.3-71.4 years). Time taken for the development of definite MS was studied by survival analysis. Cumulative event rates were; 12 months: 9%, 24 months: 15%, 36 months: 30.4%, and 60 months: 44.6%. Six of 22 patients were followed beyond 60 months. Two of these six patients developed MS later (at 66 and 112 months, respectively). Three patients remained asymptomatic despite follow-up of 10 years. CONCLUSIONS PATIENTS with RAPIDD develop MS at a similar rate to treated patients (and less frequently than placebo groups) with clinically isolated syndromes from prior randomized controlled studies. Some patients with RAPIDD continue to have radiological evolution of subclinical disease without MS symptoms despite long follow-up periods.
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Affiliation(s)
- A Siva
- Department of Neurology, Istanbul University, Cerrahpasa School of Medicine, Turkey
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La psychose maniacodépressive comme manifestation prévalente d’une sclérose en plaques. Rev Neurol (Paris) 2008; 164:472-6. [DOI: 10.1016/j.neurol.2008.02.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2007] [Revised: 09/26/2007] [Accepted: 02/08/2008] [Indexed: 11/22/2022]
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Abstract
Disorders involving regulation of affect commonly occur in multiple sclerosis (MS). These include various clinical presentations with inconsistent definitions that lead to many nomenclatures. In order to simplify the clinical approach to dysregulation of affect (DyA) a phenomenological definition was applied that unifies and combines the current classifications. Accordingly, the prevalence of DyA was determined in MS patients and comorbidity was evaluated with psychiatric disorders. Using the Structured Clinical Interview for DSM-III-R (SCID), 651 consecutive MS patients were assessed (474 female, 177 male, mean age 43.6 years, mean disease duration 11.5 years) and it was found that the prevalence of DyA was 6.5% (n = 42). In 14 patients (33.3% of DyA patients) there was no associated psychiatric comorbidity, while in 28 patients (66.6%) there was comorbid psychopathology; 12 had been suffering from psychosis (28.6%), eight from mood disorders (19%), six from cognitive decline (14.3%) and two from personality disorder (4.7%). In 15 patients (35.7%) the DyA was ego-dystonic and in 27 patients (64.3%) the symptoms of DyA were ego-syntonic. All patients with comorbid psychosis had ego-syntonic DyA. In 14.3% of patients the DyA symptomatology preceded the appearance of MS. It is concluded that the new phenomenological definition of DyA aids in distinguishing this symptom from other psychopathologies and can serve as a tool for neurologists in defining this unique entity.
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Affiliation(s)
- Yermi Harel
- Lewenstein Rehabilitation Hospital, Raanana, Israel.
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30
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Chang CH, Bourgeois JA. PATIENT MANAGEMENT PROBLEM. Continuum (Minneap Minn) 2006. [DOI: 10.1212/01.con.0000290509.34634.9a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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31
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Jongen PJH. Psychiatric onset of multiple sclerosis. J Neurol Sci 2006; 245:59-62. [PMID: 16631798 DOI: 10.1016/j.jns.2005.09.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Revised: 09/19/2005] [Accepted: 09/20/2005] [Indexed: 11/24/2022]
Abstract
We present a patient with psychotic disorder as onset of relapsing-remitting multiple sclerosis (MS). In this patient, a 26-year-old female, neurological examination revealed only minor abnormalities. As cranial CT scan was normal, her psychosis was diagnosed as psychogenic. Literature on psychiatric onset of MS is reviewed paying special attention to clinical and MRI aspects. It is concluded that psychiatric onset of MS may occur in up to 1% of patients, and that in previously healthy persons with acute psychotic disorder even the slightest neurological abnormality justifies a cranial MRI examination.
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Affiliation(s)
- Peter J H Jongen
- Multiple Sclerosis Centre Nijmegen, Heiweg 97, 6533 PA Nijmegen, The Netherlands.
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32
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Habek M, Brinar M, Brinar VV, Poser CM. Psychiatric manifestations of multiple sclerosis and acute disseminated encephalomyelitis. Clin Neurol Neurosurg 2006; 108:290-4. [PMID: 16364539 DOI: 10.1016/j.clineuro.2005.11.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
It is unusual for acute disseminated encephalomyelitis and multiple sclerosis to present as purely psychiatric disorders. We report five patients with such demyelinating diseases and symptoms of psychosis, depression or anxiety. The importance of excluding demyelination as the basis for these psychiatric disturbances is emphasized, especially in the presence of unexplained neurologic findings. The possible relationship between psychiatric symptoms and demyelinating disorders is explored.
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Affiliation(s)
- Mario Habek
- University Department of Neurology, Zagreb School of Medicine and University Hospital Center Zagreb, Kispatićeva 12, Zagreb, Croatia.
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33
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Ehrlich S, Breeze JL, Hesdorffer DC, Noam GG, Hong X, Alban RL, Davis SE, Renshaw PF. White matter hyperintensities and their association with suicidality in depressed young adults. J Affect Disord 2005; 86:281-7. [PMID: 15935248 DOI: 10.1016/j.jad.2005.01.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2004] [Accepted: 01/06/2005] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Researchers and clinicians have increasingly recognized that biological markers may help identify patients who are at risk for suicide. The objective of this retrospective, cross-sectional study was to compare the prevalence and location of white matter hyperintensities (WMH) in young inpatients with major depressive disorder (MDD) with and without histories of suicide attempts. METHODS T2-weighted magnetic resonance images (MRI) of 102 young psychiatric inpatients with MDD were rated for the presence of WMH. Medical charts were reviewed to ascertain history of suicide attempt, demographic and clinical variables. Fisher's Exact Tests and logistic regression modeling were used to test the association between WMH and suicidality. RESULTS Bivariate analysis showed that the prevalence of periventricular WMH was significantly higher in subjects with past suicide attempts (Fisher's Exact Test, p=0.02). Logistic regression analyses controlling for age, sex, and several clinical risk factors supported this finding (odds ratio=5.7; 95% confidence interval: 1.6, 21.2). LIMITATIONS Due to the retrospective, cross-sectional design of our study, we are unable to determine if the WMH preceded or followed past suicide attempts. The generalizability of our findings is limited since this group of inpatients is more severely ill than the general psychiatric population. CONCLUSIONS The increased prevalence of periventricular WMH in young adults with MDD and a history of suicide attempt, compared to similarly depressed adults without such a history, is consistent with our findings in children and youth, and suggests there might be neurobiological in addition to psychosocial risk factors for suicide.
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Affiliation(s)
- Stefan Ehrlich
- Laboratory of Developmental Psychology and Developmental Psychopathology, McLean Hospital, Harvard Medical School, Boston, MA, USA.
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Ehrlich S, Noam GG, Lyoo IK, Kwon BJ, Clark MA, Renshaw PF. White matter hyperintensities and their associations with suicidality in psychiatrically hospitalized children and adolescents. J Am Acad Child Adolesc Psychiatry 2004; 43:770-6. [PMID: 15167094 DOI: 10.1097/01.chi.0000120020.48166.93] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Increasingly, researchers and clinicians are recognizing that there may be biological markers associated with increased risk of suicide. The objective of this study was to compare white matter hyperintensities in psychiatrically hospitalized children and youth with and without a history of suicide attempt while controlling for other variables. METHOD White matter hyperintensities of 153 child and adolescent psychiatry inpatients were rated on T2-weighted magnetic resonance imaging scans using a modified Coffey scale. DSM-IV diagnosis, history of suicide attempt, and control variables such as gender, age, comorbid medical illnesses, developmental disorder, substance abuse, severity of mental illness, head injury, and possible cerebral hypoxia were obtained from discharge medical records. RESULTS Within the unipolar depression group (n = 48), white matter hyperintensities were significantly associated with a higher prevalence of past suicide attempts (Fisher exact test, p =.03). Logistic regression analysis confirmed this relationship, indicating that none of the control variables confounded our results and suggesting a specificity of 0.94. CONCLUSIONS This is the first report of an increased prevalence of white matter hyperintensities in children and youth with unipolar depression and a history of suicide attempt. Replication and expansion of our preliminary findings could be of great clinical interest.
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Affiliation(s)
- Stefan Ehrlich
- McLean Hospital, Harvard Medical School, Boston, MA 02478, USA.
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35
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Chapter 8 Neuropsychiatry: Cognition and Mood Disorders. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1877-3419(09)70037-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
OBJECTIVE Catatonic disorder due to general medical condition must be excluded in psychiatric patients presenting with this movement disorder. This report emphasizes the association of catatonia with multiple sclerosis. METHOD A patient with catatonia, psychotic depression, and the subsequent diagnosis of multiple sclerosis is described and the literature reviewed. RESULTS Mutism, immobility, cataplexy, waxy flexibility, and other aspects of catatonia occur in multiple sclerosis, usually as a consequence of a severe mood disorder and extensive cerebral demyelination. These symptoms may be the presenting manifestations of multiple sclerosis. CONCLUSIONS A high index of suspicion for neurological disease is indicated in patients with new-onset catatonia. Neuroimaging and other studies may reveal underlying demyelination requiring specific therapy.
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Affiliation(s)
- M F Mendez
- University of California at Los Angeles, USA
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37
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McDonald WI, Ron MA. Multiple sclerosis: the disease and its manifestations. Philos Trans R Soc Lond B Biol Sci 1999; 354:1615-22. [PMID: 10603614 PMCID: PMC1692676 DOI: 10.1098/rstb.1999.0506] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Multiple sclerosis is an immune-mediated inflammatory demyelinating disease of the central nervous system clinically characterized by relapses and remissions of neurological disturbance. A typical relapse, exemplified by optic neuritis, increases in severity over a week or two and after approximately one month begins to remit. Resolution takes place over the course of two to three months. In the early stages, clinical recovery is virtually complete, though persistent abnormalities of conduction can usually be detected by evoked potential techniques and persistent structural abnormalities can be detected by magnetic resonance imaging (MRI). These techniques, together with cerebrospinal fluid examination for oligoclonal IgG, provide supporting evidence for the diagnosis which, in the absence of a specific test, nevertheless remains primarily clinical. The course of the disease is very variable, but after a number of years neurological deficit begins to accumulate after each relapse. In most patients, the relapsing and remitting phase of the disease is followed by a phase of continuous progression of disability. Cognitive disturbances can be detected in many patients even quite early in the course of the illness. Deficits in attention, memory and executive skills may be prominent and tend to become increasingly prominent as neurological deficit increases, although this is not always the case. There is some correlation between the extent of MRI abnormalities in the cerebral white matter and the severity of cognitive deficit. Depression and anxiety are commonly experienced but are poorly correlated to the lesion load seen on MRI. In contrast, the much rarer psychotic symptoms, euphoria and emotional lability are closely linked to the severity of white matter disease.
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Abstract
In the last decade, major changes in our understanding of basal ganglia functions have occurred. Traditionally the basal ganglia were considered to be involved only in the modulation of movement. Recent research has suggested that the basal ganglia also take part in complex fronto-subcortical networks that have an important role in cognition reward, and mood regulation. The authors review recent findings that implicate basal ganglia abnormalities in the pathophysiology of mood disorders and discuss their potential implications for future developments in the pharmacotherapy of depressive disorder.
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Affiliation(s)
- B Lafer
- Institute of Psychiatry, University of São Paulo Medical School, Brazil
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