report

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Mental Health Consultation
Patient Name: Multiple Sclerosis Facility: XXXX
Date: 10-21-13
Additional history can be found elsewhere in this chart which will not be repeated here.
Reasonfor Referral: xx-year-old, white, xxxx, female… I was asked to evaluate her because
she is “noncompliant, anxious, c/o feeling tired all the time and has a psych history” She was
admitted from XXXX on 9-30-13 where she was treated for pneumonia and an acute delirium
“probably secondary to a flare up of Multiple Sclerosis vs. medication induced”
Background Information: CT HEAD WO CONTRAST COMPLETED:09/25/13 = “extensive old
periventricular white matter disease and multiple old lacunar and white matter infarcts”
She was described in a social work note as follows:
Current Medications: Seroquel 50mg bid, Metoprolol, Lisinopril, Pramipexole, Oxcarbazepine
450mg qhs, Valium 2.5mg q4hr prn,
Medical History: Depressive Disorder, Hyperlipidemia, Hypertension, Coronary Artery
Disease, Multiple Sclerosis, Osteoarthritis, Anxiety State, History of Stroke
Mental Status Exam: She was an alert, pear-shaped, mostly cooperative woman with slow,
perseverative, circumstantial, tangential speech laden with word finding pauses. Her affect was
flattened and when I asked repeatedly about mood she never responded but expressed overt
anger toward her family; “they folded up my apartment; took my money and put me in here”.
The “they” she was speaking of were “my daughter, mother, friend and cousin”. She went on to
complain about a “controlling mother” as if she (XXXX) was still a teenager. She also said, “I
am very careful about what I take…took a drug in the hospital that made me say thing I would
never say”. She was oriented to person, place and time. Her insight and judgment were impaired.
Findings and Recommendations: The presenting problems are classic neuropsychiatric signs
seen in Multiple Sclerosis (MS) patients (“noncompliant, anxious, c/o feeling tired all the time”).
Fatigue is often one of the most debilitating MS symptoms. The primary “lassitude” of MS is an
overwhelming sense of physical and mental exhaustion that has no identifiable cause but
significantly interferes with normal activity. The majority of patients with MS rank it as the most
disabling symptom affecting their daily lives. The literature indicates that “loss of insight” is the
most frequent neuropsychiatric sign seen in MS patients; damage to the callosal pathways causes
impairment in their ability to discriminate emotions in others, making it difficult to react to
situations in socially appropriate ways. In addition, fifty percent of MS patients experience

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depression during the course of their illness although she does not at present appear to be
clinically depressed.
She has clearly developed an MS related subcortical white matter dementia which is due to
demyelination. In an MS white matter dementia, language and general intellectual functions are
relatively well preserved. MS dementia is subtle and characterized by memory impairment, poor
judgment, lack of spontaneity, perseveration, psychomotor slowing, general dilapidation in
cognitive functioning, irritability, apathy, a frontal lobe syndrome with emotional and behavioral
disinhibition and impairment in executive functions including:
1.) abstract reasoning ability.
2.) planning and organizing ability.
3.) social judgment.
4.) problem solving and conceptual reasoning ability.
5.) capacity for self-awareness
A patient with a deficit in self-awareness shows an inability to: 1) perceive herself as others
perceive her 2) recognize her internal motivations 3) critique her own behavior
4) accurately identify her strengths and limitations 5.) change a course of action when conditions
change 6.) perceive the long-term consequences of her acts. Most patients with deficits in self-
awareness lose the ability to learn from experience, develop a generally more demanding attitude
and exhibit reduced frustration tolerance. Deficits in self-awareness worsen over time. Denial of
deficits in patients with brain disorder is commonly manifested as anger towards family
members and others because of institutional placement, which the patient believes, is
unnecessary. I have highlighted the MS dementia S/S we see in her presentation.
On top of the above, as seen on her head CT scan, she may have a subcortical arteriosclerotic
encephalopathy and does have multiple lacunar strokes leading to lacunar state. Lacunar state
due to multiple lacunar strokes often involves the basal ganglia, thalamus and internal capsule
and is characterized by gaze abnormalities, depression, apathy, emotional lability and pyramidal
and extrapyramidal symptoms. Because the thalamus is extensively and reciprocally
interconnected with all areas of the cerebral cortex even a small lesion in this structure can
predisposed a patient to delirium and arousal problems. A subcortical arteriosclerotic
encephalopathy would cause many of the same symptoms as an MS white matter dementia.
There is also a strong suggestion here of a premorbid personality disorder. However, I believe at
least some of the periventricular white matter hypodensities seen on her CT scan are related to her MS.
1. It is not clear why she is taking Oxcarbazepine she does not have a bipolar or seizure
disorder diagnosis. Euphoria is a common early sign of MS and often misdiagnosed as
mania. She does have some emotional disinhibition; perhaps it was started for this
purpose. I also noted that on the order sheet the indication given for Valium is “seizure
disorder”. We should clarify this.

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2. Modafinil (Provigil) 100 to 200 mg twice a day is often used to treat excessive daytime
drowsiness in MS patients. I think she will agree to take it once she experiences the
immediate benefit.
3. I believe she is refusing the Seroquel in part because it is sedating. Would just DC it. For
anxiety and mild disinhibition, I would like to try her on Lexapro possibly augmented by
a low dose of Abilify, which is not sedating, but she is dead set against “taking any kind
of anti-depressant”.
4. Since the MS and possibly mild VaD is causing her apathy and reduced energy, I would
not push her to be active in general. Rather, I would look for a pattern of daily fluctuation
in her arousal level and offer treatments and activities when she is likely to be most alert
and energetic.
5. It is very important here for staff to avoid appearing directive with her. She would see
this as a threat to her self-esteem and become oppositional as a means of asserting her
autonomy.
6. She tends to place responsibility for her current situation on to others. Discourage this
behavior. Remind her that she is ultimately responsible for her own choices and health
care. I believe if she was told she could leave XXXX she would not leave. We should not
call her on this, however. Just tell her we will treat her as a responsible person.
7. Encourage and allow autonomy and independence. Spend some time with her to review
all of the remaining choices she has concerning her daily life.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist