Bipolar Disorder and Multiple Sclerosis: A Case Series

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.

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

“…8,9,11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] A psychiatric event can be expressed as a pure psychiatric episode as the inaugural MS manifestation 9,[14][15][16][17][18][21][22][23][24][29][30][31]33 in association with neurological symptoms 8,14 or occurring later, after a neurological relapse. 14,19,24,27,31 Logically, the presence of neurological symptoms makes the last two presentations relatively easier to identify than the first one. Unfortunately, the first form might occur several times before a diagnosis of MS is considered.…”

“…Unfortunately, the first form might occur several times before a diagnosis of MS is considered. 14,20,31 The resemblance of psychiatric symptoms in MS to those observed in pure psychiatric disorders 32 makes it even more difficult for psychiatrists to differentiate between the two. However, this scenario could be avoided if physicians rely on some red flags in the history and physical exam.…”

“…However, this scenario could be avoided if physicians rely on some red flags in the history and physical exam. Late-onset psychiatric symptoms, 20,26 negative personal or family history of psychiatric diseases, 21,26,27,29,31,33 positive family history of MS, 24,25 and presence of cognitive decline 15,26 should raise further attention to the etiology of symptoms and prompt physicians to consider organic causes.…”

“…36 Although the neurological exam might be unremarkable, 14,37 the presence of minor abnormalities constitutes a warning sign that can guide clinicians to the correct diagnosis. 8,15,21,24,26,31 Further clues could be obtained from response to treatments. The classical management of any psychiatric symptom consists of the introduction of appropriate and commonly used medications, such as, antidepressants, anxiolytics, and antipsychotics.…”

“…However, it is worth noting that this side effect is transient and not constant 45 and thus should not limit or postpone steroid therapy. 31 Symptomatic treatment options are also very important in MS management and have shown some efficacy in ameliorating various symptoms, including cognitive decline, spasticity, pain, and bladder dysfunction. 42 Moreover, since pharmacological treatment alone does not always lead to satisfactory results, rehabilitation and alternative interventions are required to optimize the therapeutic strategies.…”