Learning outcomes: Recognition and treatment of depression and anxiety in MS Recognise sudden changes in emotional state (laughter, crying, anger) Recognition of mania and psychosis in MS Cognitive impairment

1. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
Dr Simon Harrison
Locum Consultant Neuropsychiatrist, Maudsley Hospital, London
simon.harrison@slam.nhs.uk

2. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
Learning outcomes
• recognition and treatment of depression and anxiety in MS
• Recognise sudden changes in emotional state (laughter, crying, anger)
• Recognition of mania and psychosis in MS
• Cognitive impairment

3. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
Learning outcomes
• recognition and treatment of depression and anxiety in MS
• recognise sudden changes in emotional state (laughter, crying, anger)
• recognition of mania and psychosis in MS
• cognitive impairment

4. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex; organic
2. How psychiatrists think
3. Depression
4. Anxiety
5. Pseudobulbar affect
6. Mania, psychosis
7. Cognitive impairment

5. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
1.1 Common, wide range
‘Organic’: (cognitive impairment, PBA)
Generally fit with usual psychiatric categories, approaches
As with underlying pathology, other symptoms:
variations in type, severity, course
1.2 Many questions unanswered….
2. How psychiatrists think
3. Depression
4. Anxiety
5. Pseudobulbar affect
6. Mania, psychosis
7. Cognitive impairment

6. Estimates of
prevalence
(%)
Point
MS
Lifetime
MS
Lifetime
general
population
Mood
disorders
Major Depressive
Disorder
14-272 36 - 541 16.21
Bipolar affective
disorder
131 1-4.51
Suicidal thoughts Up to 251 176
Suicide At least twice as common1
2-7.5 times higher 2
Anxiety disorders Adjustment
disorder
221 0.2-2.31
Anxiety disorders Up to 502 35 -372 14.63
Disorders of
Affect
PBA 6.5-46.21
Up to 102
Euphoria Unknown1
105
Psychotic
disorders
2-31
1.12
1.81
Cognitive
impairment
40-652
40-704
Dementia >65: 5
>80: 207
1.1 The territory: table of estimates of prevalence

7. Estimates
(%)
Point prevalence
(household
population)
Lifetime
prevalence
(household
population
Depression 2.6
Suicidal
thoughts
17
Anxiety 4.7 Suicide attempt 5.6
Mixed anxiety
and depression
9.7
Self-harm 3
PTSD 3.0 Bipolar Affective 1-3
Phobias 2.6 Schizophrenia 1-3
Eating disorders 1.6
Personality
Disorders
3-5
OCD 1.3
Panic disorder 1.2
1.2 The territory: 2007 UK Household survey 2007

8. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
1.1 Common, wide range
Generally fit with usual psychiatric categories, approaches
Some more ‘organic’ (PBA, cognitive impairment)
As with underlying pathology, other symptoms:
variations in type, severity, course
1.2 Many questions unanswered
AAN Guidelines (2014)
NICE Guidelines (2014)
2. How psychiatrists think
3. Depression
4. Anxiety
5. Pseudobulbar affect
6. Mania, psychosis
7. Cognitive impairment

9. 1.2 AAN Guidelines (2004): Nine questions, tentative answers for three
1. What clinical evaluation procedures and screening and diagnostic tools can
be used to accurately identify symptoms and make diagnoses of emotional
disorders in individuals with MS?
Consider CNS-LS (pseudobulbar affect)
BDI (depressive disorder)
2-question tool ((depressive disorder)
GHQ (emotional disturbance)
2. What are the effective treatments for disorders of mood …?
Consider telephone CBT
3. What are the effective treatments for disorders of affect … ?
Consider dextromethorphan/quinidine
4. What are the effective treatments for psychotic disorders …?
5. What clinical evaluation procedures and screening and diagnostic instruments
can be used to accurately distinguish between MS fatigue and depression …?
6. What are the effects of disease-modifying agents on mood and affect … ?
7. What are the effects of corticosteroids on mood and affect …?
8. What are the effects of symptomatic treatments on mood and affect …?
9. What are the risk factors for suicidal thinking and behavior among individuals
with MS?

10. 1.2 NICE CG186 (2014)
1.3.1 Care for people with MS using a coordinated multidisciplinary approach.
Involve ….
• speech and language therapists, psychologists, dietitians, social care and
continence specialists…

11. 1.2 NICE CG186 2014
1.5 MS symptom management and rehabilitation
…
1.5.2 Assess and offer treatment to people with MS who have fatigue for anxiety,
depression, difficulty in sleeping, and any potential medical problems such as
anaemia or thyroid disease.
…
1.5.28 Consider amitriptyline to treat emotional lability in people with MS.
….
1.5.31 Be aware that the symptoms of MS can include cognitive problems,
including memory problems that the person may not immediately recognise or
associate with their MS.
1.5.32 Be aware that anxiety, depression, difficulty in sleeping and fatigue can
impact on cognitive problems. If a person with MS experiences these symptoms
and has problems with memory and cognition, offer them an assessment and
treatment.
1.5.33 Consider referring people with MS and persisting memory or cognitive
problems to both an occupational therapist and a neuropsychologist to assess
and manage these symptoms.

12. NICE CG186 (2004)
1.6 Comprehensive review
1.6.3 Tailor the comprehensive review to the needs of the person with MS
assessing:. …
- depression (see Depression in adults with chronic physical health
problems NICE clinical guideline 91) and anxiety (see Generalised anxiety
disorder and panic disorder NICE clinical guideline 113)
…
Information about treating a relapse with steroids
1.7.12 Explain the potential complications of high-dose steroids, for example
temporary effects on mental health (such as depression, confusion and
agitation) and worsening of blood glucose control in people with diabetes.

13. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
2. How psychiatrists think
Biopsychosocial
Predisposing, precipitating, perpetuating
History, examination, investigation, diagnosis, management
3. Depression
4. Anxiety
5. Pseudobulbar affect
6. Mania, psychosis
7. Cognitive impairment

14. Pre-
disposing
Pre-
cipitating
Per-
petuating
MS
Biological Underlying pathology
brain lesions;
immune dysfunction
Related impairments
Pain
Fatigue
Cognitive impairment
Treatment
Psychological Loss
Uncertainty,
unpredictability
Stress
Coping strategies
Social Disabilities (activity
limitation; participation
restriction)
Impact on family, carers
2.1 How Psychiatrists Think: 1 an overall framework

15. 2.2 How psychiatrists think: The medical structure
History Including
Past psychiatric history
Personal history
Premorbid personality
Substance misuse
Medical
Medication
Collateral
Examination Appearance & Behaviour
Speech
Mood, affect (subjective, objective)
Thoughts (form, content)
Perception
Cognition
Insight
Investigations
Diagnosis , formulation Risk
Management Risk

18. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
2. How psychiatrists think
3. Depression
3.1 Recognition important clues: history, core & thoughts
3.2 Approach: consider all potential factors
3.3 Treatment: CBT, SSRIs
3.4 Suicide: always ask
4. Anxiety
5. Pseudobulbar affect
6. Mania, psychosis
7. Cognitive impairment

19. 3. Depression. 3.1 Recognition
DSM-5 (IV) symptoms of major depressive episode: 5/9 ( either 1 or 2)
1. Depressed mood most of the day, nearly every day, as indicated by either subjective
report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears
tearful). (Note: children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5%
of body weight in a month), or decrease or increase in appetite nearly every day. (Note:
In children, consider failure to make expected weight gain).
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy or nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to concentrate, or indecisiveness, nearly every day (either by
subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without
a specific plan, or a suicide attempt or a specific plan for committing suicide.

20. DSM-V Symptoms Important clues in MS
Low mood Pervasive mood change
Diurnal variation
Anhedonia
Appetite, weight change
Insomnia, hypersomnia
Psychomotor agitation, retardation
Fatigue, loss of energy
Worthlessness, guilt Pessimistic or negative thoughts and
patterns of thinking:
Beck’s cognitive triad (self, world, others)
Poor concentration
Suicidal thoughts Suicidal thoughts
Change in function not related / out of
proportion to physical disability
Mood-congruent psychotic symptoms
3. Depression. 3.1 Recognition

21. AAN Guidelines (2014): BDI, 2-question tool, GHQ
Other suggestions: PHQ-9, HADS, CES-D
NICE (CG91, 2009) Two questions
[1.3.1.1]
“During the last month, have you often been bothered by feeling down,
depressed or hopeless?
During the last month, have you often been bothered by having little
interest or pleasure in doing things?”
3. Depression. 3.1 Recognition. Screening tools

22. 1.3.1 Case identification and recognition
1.3.1.1 Be alert to possible depression (particularly in patients with a past
history of depression or a chronic physical health problem with associated
functional impairment) and consider asking patients who may have depression
two questions, specifically:
• During the last month, have you often been bothered by feeling down,
depressed or hopeless?
• During the last month, have you often been bothered by having little interest
or pleasure in doing things?
1.3.1.2 If a patient with a chronic physical health problem answers 'yes' to either
of the depression identification questions (see 1.3.1.1) but the practitioner is
not competent to perform a mental health assessment, they should refer the
patient to an appropriate professional. If this professional is not the patient's
GP, inform the GP of the referral.
3. Depression. 3.1 Recognition. NICE CG91

23. NICE (CG91, 2009)
1.3.1.3 If a patient with a chronic physical health problem answers 'yes' to either
of the depression identification questions (see 1.3.1.1), a practitioner who is
competent to perform a mental health assessment should:
• ask three further questions to improve the accuracy of the assessment of
depression, specifically:
• during the last month, have you often been bothered by feelings of
worthlessness?
• during the last month, have you often been bothered by poor
concentration?
• during the last month, have you often been bothered by thoughts of
death?
• review the patient's mental state and associated functional, interpersonal
and social difficulties
• consider the role of both the chronic physical health problem and any
prescribed medication in the development or maintenance of the depression
• ascertain that the optimal treatment for the physical health problem is being
provided and adhered to, seeking specialist advice if necessary.
3. Depression. 3.1 Recognition: NICE

24. DSM-V Symptoms Important clues in MS
Low mood Pervasive mood change
Diurnal variation
Anhedonia
Appetite, weight change
Insomnia, hypersomnia
Psychomotor agitation, retardation
Fatigue, loss of energy
Worthlessness, guilt Pessimistic or negative thoughts and
patterns of thinking:
Beck’s cognitive triad (self, world, others)
Poor concentration
Suicidal thoughts Suicidal thoughts
Change in function not related / out of
proportion to physical disability
Mood-congruent psychotic symptoms
3. Depression. 3.1 Recognition

25. 3. Depression. Risk Factors
In general
Loss,
trauma
Family history
More common in women
In MS (Barmer et al 2008)
Shorter disease duration
Greater disease severity
Lower age
Lower education
Less social support
But not extent of disability

26. 3. Depression. 3.2 Approach
1. Exclude, treat organic causes
2. NICE: ‘ascertain that the optimal treatment for the physical health
problem is being provided and adhered to, seeking specialist advice if
necessary.’
3. Medication?
NB: history (changes, compliance)
Steroids
Antispasticity drugs: baclofen, dantrolene, tizanidine
Interferon? ‘unclear, but it is now thought that depression
occurs no more frequently in people treated with interferon-
beta.’ MPG 12

27. 3. Depression. 3.2 Approach
4. Potential contributory factors
4.1 Pain: chronic pain: 50% of MS
But of those with pain: pain with depression: 6-19%
If depressed, more likely to report pain, than vice versa
4.2 Fatigue: complex, highly correlated.
4.3 Anxiety: also common in MS (x3 more, comorbid with
depression in over half people with MS and depression.
4.3 Alcohol misuse: as in general population
4.4 Cognitive impairment?

28. Pre-
disposing
Pre-
cipitating
Per-
petuating
MS
Biological Underlying pathology
brain lesions;
immune dysfunction
Related impairments
Pain
Fatigue
Cognitive impairment
Treatment
Psychological Loss
Uncertainty,
unpredictability
Stress
Coping strategies
Social Disabilities (activity
limitation; participation
restriction)
Impact on family, carers
2.1 How Psychiatrists Think: 1 an overall framework

29. 3. Depression. 3.2 Treatment
Non-pharmacological
CBT
(AAN 2014: 16 week programme of T-CBT is possibly effective)
NICE CG91 (chronic physical health problem)
Recommendations around
• persistent subthreshold depressive symptoms or mild to moderate
depression
General measures: Sleep hygiene
Low-intensity psychosocial: structured group physical activity; group-based
peer support (self help) programme, individual guided self help (based on CBT),
computerised CBT
• Persistent subthreshold depressive symptoms or mild to moderate
depression with inadequate response to initial interventions, and
moderate to severe depression
High intensity: Group-based CBT, individual CBT, behavioural couples
therapy
Individual CBT + antidepessant (severe)

30. 3. Depression. 3.2 Treatment
Non-pharmacological
Medication:
Little evidence, but SSRIs first line (relatively benign side effects, limited
interactions)
Also used: SNRIs (venlafaxine, duloxetine)
Some evidence for desipramine (TCA), moclobemide (MAOI)
Start low (from an initial half dose): tolerability of side effects
(Not St John’s Wort)
Consider: side effects, interactions
Other:
ECT: may be a trigger for relapse of MS symptoms although some studies
suggest that no neurological disturbance occurs. (MPG12)

31. 3. Depression. 3.2 Treatment
Antidepressant side effects
SSRIs: common, mild, usually brief; vary between drugs
Common: nausea, upper GI disturbance, changes in sexual function
Also: Agitation, headache.
Also: GI bleeds (SSRIs + NSAIDS (gastroprotection); warfarin/heparin; aspirin
TCAs: (e.g. desipramine; amitryptiline). sedation, dry mouth, blurred vision,
urinary retention ; hypotension, tachycardia, QTc prolongation
MAOIs: (e.g. moclobemide) hypotension, dizziness, drowsiness, insomnia,
headaches, dry mouth, nervousness, weight gain. Hypertensive crisis (tyramine).
Hyponatraemia: all antidepressants: usually within 30 days, not dose related).
Dizziness, nausea, lethargy, confusion, cramps, seizures.
Suicidality
Some concern increased risk of suicidal thoughts (particularly young people)
with antidepressants
But low absolute risk, treatment of depression most effective prevention suicidal
thoughts).

32. 3. Depression. 3.2 Treatment
Side Effects in More Detail
SSRIs
Citalporam Nausea, vomiting, dyspepsia, abdominal pain, diarrhoea, rash,
agitation, anxiety, headache, insomnia, tremor, sexual
dysfunction (male and female), hyponatraemia, cutaneous
bleeding disorders.
Fluoxetine As citalopram, but insomnia, agitation possibly more common
Paroxetine As citalopram, but antimuscarinic effects & sedation more
common
Sertraline As citalopram
Others
Duloxetine Nausea, insomnia, headache, dry mouth, somnolence,
constipattion, anorexia. V. small increase in HR, BP, including hypertensive crisis
Venlafaxine Nausea, insomnia, dry mouth, somnolence, dizziness, sweating,
nervousness, headache, sexual dysfunction, constiptation. High BP at higher doses;
avoid if risk of arrythmia;. Discontinuation symptoms commmon
Mirtazapine Increased appetite, weight gain, drowsiness, oedema, dizziness,
headache, blood dyscrasia. Nausea, sexual dysfunction relatively uncommon.

33. 3. Depression. 3.2 Treatment
Side Effects in More Detail
TCA
Amitryptyline Sedation , often with hangover; postural hypotension;
tachycardia/arrythmia; dry mouth, blurred vision, constipation,
urinary retention
Nortryptyline As amitryptiline, but less sedative/anticholinergic, hypotensive;
constipation may be problematic
Clomipramine, As amitryptiline
Imipramine, Lofepramine: as amitryptiline
MAOIs
Moclobemide (reversible MAO-A inhibitor): sleep disturbances, nausea, agitation,
confusion
Isocarboxazid Postural hypotension, dizziness, drowsiness, insomnia,
headaches, oedema, anticholinergic side effects, nervousness, paraesthesia, weight
gain, hepatotoxicity, leucopenia, hypertensive crisis
Phenelzine As Isocarboxazid, but more post. Hypotension, less
hepatotoxicity
Tranyclcypromine As Isocarboxazid, but insomina, nervousness, hypertensive crisi
more common than other MAOIs, hepatotoxicity less common; mild dependence

34. 3. Depression. 3.2 Treatment
Other considerations with antidepressants
Interactions
NICE guidelines CG91: 1.5.2.6ff.
GI bleeds (SSRIs: NSAIDS (gastroprotection); aspiring warfarin, heparin,
aspiring
Serotonin syndrome with other serotingergic agents (e.g.TCAs for pain,
bladder)
Rare, severe usually if with MAOIs
Triad: neuromuscular excitation
(e.g. clonus, hyperreflexia, myoclonus, rigidity
autonomic nervous system excitation
(e.g hyperthermia, tachycardia)
altered mental state
(e.g. agitation, confusion)

35. Depression. 3.2 Treatment
SSRI discontinuation symptoms
Usually within 5 days of stopping usually mild, self-limiting
Domains
Vasomotor (e.g. sweating)
GI (e.g. nausea)
Neuromotor (ataxia)
Neurosensory (parasthesiae)
Affective (e.g. irritability)
Other (e.g. increased dreaming)

36. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
2. How psychiatrists think
3. Depression
3.1 Recognition important clues: history, core & thoughts
3.2 Approach: consider all potential factors
3.3 Treatment: CBT, SSRIs
3.4 Suicide: always ask
2. Anxiety
3. Pseudobulbar affect
4. Mania, psychosis
5. Cognitive impairment

37. Estimates of
prevalence
(%)
Point
MS
Lifetime
MS
Lifetime
general
population
Mood
disorders
Major Depressive
Disorder
14-272 36 - 541 16.21
Bipolar affective
disorder
131 1-4.51
Suicidal thoughts Up to 251 176
Suicide At least twice as common1
2-7.5 times higher 2
Anxiety disorders Adjustment
disorder
221 0.2-2.31
Anxiety disorders Up to 502 35 -372 14.63
Disorders of
Affect
PBA 6.5-46.21
Up to 102
Euphoria Unknown1
105
Psychotic
disorders
2-31
1.12
1.81
Cognitive
impairment
40-652
40-704
1.1 The territory: table of estimates of prevalence

38. 3. Depression. 3.2 Suicide
NICE (CG91, 2009)
1.1.3.6 Always ask patients with depression and a chronic physical health
problem directly about suicidal ideation and intent. If there is a risk of self-harm
or suicide:
• assess whether the patient has adequate social support and is aware of
sources of help
• arrange help appropriate to the level of risk (see section 1.3.2)
• advise the patient to seek further help if the situation deteriorates.

39. 3. Depression. 3.2 Suicide
NICE (CG91, 2009)
1.3.2 Risk assessment and monitoring
1.3.2.1 If a patient with depression and a chronic physical health problem presents considerable
immediate risk to themselves or others, refer them urgently to specialist mental health services.
1.3.2.2 Advise patients with depression and a chronic physical health problem of the potential for
increased agitation, anxiety and suicidal ideation in the initial stages of treatment for depression;
actively seek out these symptoms and:
• ensure that the patient knows how to seek help promptly
• review the patient's treatment if they develop marked and/or prolonged agitation.
1.3.2.3 Advise a patient with depression and a chronic physical health problem, and their family or
carer, to be vigilant for mood changes, negativity and hopelessness, and suicidal ideation, and to
contact their practitioner if concerned. This is particularly important during high-risk periods, such as
starting or changing treatment and at times of increased personal stress.
1.3.2.4 If a patient with depression and a chronic physical health problem is assessed to be at risk of
suicide:
• take into account toxicity in overdose if an antidepressant is prescribed or the patient is taking
other medication; if necessary, limit the amount of drug(s) available consider increasing the level of
support, such as more frequent direct or telephone contacts
• consider referral to specialist mental health services.

40. 3. Depression. 3.2 Suicide
Suicidal thoughts: common
Feinstein (2002) Clinic sample: 28.6% lifetime prevalence of suicidal intent;
6.4% previous attempt
Suicide
Kahana et al. (1971) 3% died by suicide over a 3 year period
Sadovnick et al. (1991) 15% of deaths over 16 year period
Risk Factors in MS
1. Male
2. Young at age of onset of illness
3. Social Isolation
4. Substance Misuse
5. Current or previous history of depression

41. Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
2. How psychiatrists think
3. Depression
3.1 Recognition important clues: history, core & thoughts
3.2 Approach: consider all potential factors
3.3 Treatment: CBT, SSRIs
3.4 Suicide: always ask
4. Anxiety
5. Pseudobulbar affect, euphoria
6. Mania, psychosis
7. Cognitive impairment

42. Estimates of
prevalence
(%)
Point
MS
Lifetime
MS
Lifetime
general
population
Mood
disorders
Major Depressive
Disorder
14-272 36 - 541 16.21
Bipolar affective
disorder
131 1-4.51
Suicidal thoughts Up to 251 176
Suicide At least twice as common1
2-7.5 times higher 2
Anxiety disorders Adjustment
disorder
221 0.2-2.31
Anxiety disorders Up to 502 35 -372 14.63
Disorders of
Affect
PBA 6.5-46.21
Up to 102
Euphoria Unknown1
105
Psychotic
disorders
2-31
1.12
1.81
Cognitive
impairment
40-652
40-704
1.1 The territory: table of estimates of prevalence

43. 4. Anxiety
Common in MS: three times general population of
generalised anxiety disorder, panic disorder, OCD, social phobia
Recognition: overlap of somatic symptoms;
complex relationship with depression, cognitive impairment
Therefore: thoughts, behaviours (avoidance)
Anxiety disorders
Phobias provoked : agoraphobia, social, specific
Panic disorder
Generalised AD
OCD Obsessions, compulsions
Stress related PTDS, adjustment reactions
(Somatoform: Dissociative (conversion); somatisation, hypochondriasis)
Treatment: generally as for non-MS,
SSRIs, CBT

44. 5. Disorders of Affect
5.1 Pseudobulbar affect (Pathological Laughing and Crying)
Uncontrollable laughing and/or crying without the associated subjective feelings of
happiness or sadness and usually without any discernible stressor.
Some may also display outbursts of anger or frustration.
10%; associated long disease duration, progressive course, cognitive impairment,
greater physical disability.
PBA in neurological conditions: associated with depression, impairments in
executive function, sexual function, ADLs
5.2 Euphoria
A fixed mental state change (rather than fluctuating as in mania) distinguished by
lack of concern over physical disability and incongruous optimism.
Lacks overactivity of mania
(10% prevalence; Associated with: more severe MS, greater physical disability,
cognitive dysfunction, lack of insight, several (usually frontal) brain lesion load.

45. Work et al. Pseudobulbar Affect: an Under-recognized and
Under-treated Neurological Disorder Adv Ther (2011) 28(7):586-601.

46. Center for Neurologic Study-Lability Scale (CNS-LS) for pseudobulbar affect

49. 75% some psychiatric abnormality
61% intellectual deterioration
(mild-profound)
(0% in controls)
40% personality changes
(33% controls)
53% abnormalities of mood
(13% in controls)
27% depressed
26% euphoric
10% exaggerated emotional
expression
Euphoria: correlated intellectual
deterioration; associated with denial of
disability (seen in 11%)
Psychosis: rare
N: 108
Controls: muscular dystrophy

50. 5. Disorders of Affect. Treatments
PBA NICE 2014 Amitryptiline
AAN 2014 Nuedextra (dextromethorphan/quidine)
Euphoria ?

51. Estimates of
prevalence
(%)
Point
MS
Lifetime
MS
Lifetime
general
population
Mood
disorders
Major Depressive
Disorder
14-272 36 - 541 16.21
Bipolar affective
disorder
131 1-4.51
Suicidal thoughts Up to 251 176
Suicide At least twice as common1
2-7.5 times higher 2
Anxiety disorders Adjustment
disorder
221 0.2-2.31
Anxiety disorders Up to 502 35 -372 14.63
Disorders of
Affect
PBA 6.5-46.21
Up to 102
Euphoria Unknown1
105
Psychotic
disorders
2-31
1.12
1.81
Cognitive
impairment
40-652
40-704
1.1 The territory: table of estimates of prevalence

52. 6. Mania, Psychosis
6.1 Mania
Elevated mod, increased energy, overactivity, pressure of speech, decreased need
for sleep, poor attention, distractible; grandiosity; disinhibition.
Possible causation: Steroids
Baclofen, dantrolene, tizanidine
Treatment: mood stabilisers: sodium valproate (better tolerated than lithium: can
causes diruesis); antipsychotics (olanzapine, risperidone)
6.2 Psychosis
Disordered thought (subjective; objective); perception (delusions, paranoia,
hallucinations); lack of insight.
Possible causation: Steroids. Cannabinoids?
Treatment: atypical antipsychotics (risperidone, clozapine)
6.3 Delirium
Disturbance of consciousness (reduced clarity of awareness), poor attention.
Change in cognition Brief period of development, fluctuating over course of day.

53. Estimates of
prevalence
(%)
Point
MS
Lifetime
MS
Lifetime
general
population
Mood
disorders
Major Depressive
Disorder
14-272 36 - 541 16.21
Bipolar affective
disorder
131 1-4.51
Suicidal thoughts Up to 251 176
Suicide At least twice as common1
2-7.5 times higher 2
Anxiety disorders Adjustment
disorder
221 0.2-2.31
Anxiety disorders Up to 502 35 -372 14.63
Disorders of
Affect
PBA 6.5-46.21
Up to 102
Euphoria Unknown1
105
Psychotic
disorders
2-31
1.12
1.81
Cognitive
impairment
40-652
40-704
Dementia >65: 5
>80: 207
1.1 The territory: table of estimates of prevalence

54. 7. Cognitive impairment
Presentation and course: variable
Common: 30-40% (community patients) 60% (clinic)
May not be recognised (preserved language; MMSE not useful)
Most commonly affected functions
1. Memory impairment
Difficulty in learning new information, remembering recent conversations,
following books, films, keeping appointments
2. Slowed information processing speed:
Difficulty in keeping up with conversations, processing incoming information
(particularly from multiple sources at same time); multi-tasking, thinking feels
slowed
3. Impaired executive function
Difficulty with organizing, planning, prioritizing, sequencing, abstract reasoning
4. Visual/spatial processing
Difficulty in reading maps, diagrams, left-right orientation, navigation.

55. 7. Cognitive impairment
Possible drug effects
tizanidine
diazepam
gabapentin
Complicating factors
Depression, anxiety
Tests
MMSE not useful
Screening: MS Neuropsychological Screening Questionnaire
Neuropsychometry: Miminal Assessment of Cognitive Function in MS
Treatment
Disease Modifying Therapies
Not dementia drugs (cholinesterase inhibitors, memantine)
Cognitive Rehabilitation
- restoration of function (remedial therapies)
- compensatory strategies

56. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
1. The territory: variable, multifactorial, complex
2. How psychiatrists think
Biopsychosocial; Predisposing, precipitating, perpetuating
History, examination, investigation, diagnosis, management
ICD-10, DSM
3. Depression
3.1 Recognition important clues: history, core & thoughts
3.2 Approach: consider all potential factors
3.3 Treatment: CBT, SSRIs
3.4 Suicide: always ask
2. Anxiety
3. Pseudobulbar affect
4. Mania, psychosis
5. Cognitive impairment

57. MS Trust Conference 2015
Abnormal mental states and behaviours in MS
Learning outcomes
• recognition and treatment of depression and anxiety in MS
• Recognise sudden changes in emotional state (laughter, crying, anger)
• Recognition of mania and psychosis in MS
• Cognitive impairment