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(ECTRIMS) Neuropsychiatric disorders in MS

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PostPosted: Sun Oct 06, 2013 3:38 pm    Post subject: (ECTRIMS) Neuropsychiatric disorders in MS Reply with quote

Presented at the annual ECTRIMS conference in Copenhagen, October 2-5, 2013:

Neuropsychological challenges in MS

Thursday, October 03, 2013, 10:45 - 11:05

Neuropsychiatric disorders in multiple sclerosis

A. Feinstein (Toronto, CA)

MS is associated with widespread neuropsychiatric disturbances that include major depression, sub-syndromal depression, bipolar affective disorder, euphoria, pseudobulbar affect, psychosis and personality change. The lifetime prevalence of major depression approaches 50%, well above that in the general population and most other neurological disorders. Depression is an important determinant of quality of life, can further exacerbate cognitive dysfunction and is a major determinant of suicidal intent in MS patients. It has been linked to the presence of increased lesion volume, atrophy and diffusion tensor imaging abnormalities in medial prefrontal, anterior and medial temporal legions. Brain metrics, however, account for less than 50% of the variance in explaining the presence of depression and a host of psychosocial factors are of etiological relevance too, including dysfunctional coping styles. Depression in MS responds modestly at best to antidepressant medication where anticholinergic side effects can limit attaining a therapeutic dosage.

A Cochrane review has concluded that Cognitive Behavior Therapy is effective in treating MS related depression and can be administered with good effect over the telephone as well, a finding of particular relevance in a disease such as MS. Mindfulness therapy has also been used successfully to treat depression.

Pseudobulbar affect (PBA) can affect up to 10% of MS patients. It is defined as laughter without mirth and crying without sadness. Some patients can present with a mix of uncontrollable laughing and crying. Brain imaging has revealed an association with parietal, orbitofrontal, cerebellar and brain stem regions. PBA responds well to pharmacotherapy, including low dose tricyclic antidepressants, selective serotonin reuptake inhibitors, levodopa and Neudexta, the latter a combination of dextromethorphan and quinidine.

Bipolar Affective Disorder is twice as common in MS patients as the general population. The clinical picture is defined by elevated or irritable mood, grandiose or persecutory beliefs and increased physical activity (rapid speech, less need for sleep, high energy etc). There are no treatment studies and the neuropsychiatrist must "borrow" from general psychiatry principles which include the use of mood stabilizing medication such as lithium carbonate, sedation with benzodiazepines for agitation the use of antipsychotic medication should the patient be delusional.

Euphoria is defined as a fixed state of wellbeing notwithstanding often advanced disability. It is associated with progressive disease, a high EDSS, a large lesion load, significant cerebral atrophy and marked cognitive compromise. There is no treatment for euphoria. The burden here most often falls on family members and caregivers.

Psychosis akin to a schizophrenia-type picture occurs more frequently by chance in MS patients, particularly in younger patients. As with bipolar affective disorder there is no MS related treatment algorithm to follow and as such general psychiatry treatment regimes must be followed, albeit with the important neuropsychiatric caveat - start low and go slow - when it comes to medication.
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