Suspect Autoimmune or demyelinating disorder if.. 1. Fatigue or cognitive impairment out of proportion to the mood symptoms or depression 2. Atypical presentation 3. Not responding to anti-depressants or anti-psychotics 4. Presence of EPS with minimal dose of typical anti-psychotics -- To monitor BP and electrolytes if we suspect any autoimmune disorders

1. NEUROPSYCHIATRIC ASPECTS OF
DEMYELINATING & AUTOIMMUNE
DISORDERS
PRESENTOR - DR.SRAVANTHI.P
CHAIR PERSON -
DR.GOPALAKRISHNAN.S.B
&
DR.SIVABACKIYA.C CHRI, 2018 1

2. OVERVIEW
AUTOIMMUNE DISORDERS
INTRODUCTION
CONDITIONS
• SYSTEMIC LUPUS
ERYTHEMATOSIS
• ANTI-NMDA RECEPTOR
ENCEPHALITIS
• PSORIASIS
• RHEUMATOID ARTHRITIS
• ADDISONS DISEASE
• MYASTHENIA GRAVIS
• ANTI-PHOSPHOLIPID SYNDROME
• OTHERS
DEMYELINATING DISORDDERS
INTRODUCTION
CONDITIONS
• MULTIPLE SCLEROSIS
• VITAMIN B12 DEFICIENCY
• CENTRAL PONTINE
MYELINOLYSIS
• METACHROMATIC
LEUKODYSTROPHY
• DUE TO TREATMENT OF
AUTOIMMUNE &
DEMYELINATING DISORDERS.
CHRI, 2018 2

3. AUTOIMMUNE
DISORDERS
CHRI, 2018 3

4. INTRODUCTION
•An autoimmune disease is an illness that causes the immune
system to produce antibodies that attack normal body
tissues.1
•In 1895, William Osler , for the first time, gave the description
of an autoimmune disease affecting the brain (psychosis in
SLE) 2
•The production of auto antibodies against neuronal antigens
can interfere with synaptic transmission causing direct
neuronal injury. 3
CHRI, 2018 4

5. CHRI, 2018 5

6. NEURO-PSYCHIATRIC MANIFESTATIONS
Neuro-psychiatric manifestations vary in severity and symptomatology
based on the organ involved.
The most common psychiatric manifestations:
•Progressive cognitive dysfunction
•Emotional instability
•Sleep disorders
•Depersonalization and derealization
•Depression
•Anxiety
•Psychotic symptoms (referential delusions and hallucinations)
CHRI, 2018 6

7. • A 16-year old girl was brought to ER with 7days history of gradual
progression of
o headache, body ache & loss of appetite
o excessive talking, muttering, tearfulness and irritability
o withdrawn and non-communicative.
• On examination, waxy flexibility, negativism, and immobility were found.
• Diagnosed as Acute psychosis with catatonic features and treated with
lorazepam 4-6mg/day and Risperidone 2-4 mg/day. Due to slow
improvement, 6 ECTs were given.
• Patient worsened after moderate improvement and a facial butterfly rash
developed.
• Patient was subjected to LE Cell test and Anti-DS DNA test, both of which
were positive.
CASE VIGNETTE – 14
CHRI, 2018 7

8. CASE VIGNETTE -2 5
41 year Man presented to Psychiatric OPD with
Depressive symptoms for 2 months with complaints of hearing his
deceased wife’s voice in the house occasionally.
Started on psychotherapy sessions (twice monthly) and 20mg of
fluoxetine daily.
After 2 weeks , reported no improvement in symptoms and complained
of death wishes , however no suicidal ideas – Continued Fluoxetine and
Psychotherapy once weekly sessions – lost to followup.
Four months later, presented to ER with delirium, mild fever, and visual
and auditory hallucinations with examination and lab findings of weak,
thready pulse, severe hypotension (70 systolic), and severe hyponatremia
and hyperkalemia.
Diagnosed as ADDISONIAN CRISIS and treated in ICU .
CHRI, 2018 8

9. SLE
• Chronic disease that causes
inflammation in connective
tissues which provide flexibility
to body structures.
• Skin changes are frequent, with
classical butterfly eruption over
nose and cheeks.
• With early detection and
effective treatment with
steroids, it mostly may present
as recurrent mild illness with
prolonged asymptomatic CHRI, 2018 9

10. CHRI, 2018 10

11. NEUROPSYCHIATRIC
MANIFESTATIONS 6,7
Can be the earliest manifestations
of SLE.
In up to 40% , seen during the
first year of SLE diagnosis.
Can occur independently of active
systemic disease and without
serologic activity.
Prevalence of NPSLE
• 14% - 80% in adults
• 22% - 95% in children
Cognitive impairment (20-80%)
Depression (65%)
Anxiety(40%)
Psychosis (2-11%)
Delirium(1-7%)
CHRI, 2018 11

12. COGNITIVE IMPAIRMENT & SLE
 Seen in 75% patients with NPSLE
 Generally Mild , often transient
 Components affected
 Attention and concentration
 Memory and processing speed
 Executive and visuospatial problems.
 Greater cognitive impairment seen in those with steroid use or
comorbid depression.
 Degree of impairment is associated with severity of illness
CHRI, 2018 12

13. DEPRESSION & SLE
In patients with depression in SLE , symptoms commonly seen
are
•Fatigue
•Reduced muscle strength
•Sleep disturbance
•Pain
CHRI, 2018 13

14. Depressi
on &
SLE8
High dose
Prednisolo
ne
Recent
SLE
diagnosis
Non-
Asian
Ethnicity
Cutaneou
s disease
Comorbid
neural
involveme
nt
Anti-RiboP;
Anti-NMDA
R
CONTRIBUTING FACTORS FOR
DEPRESSION
CHRI, 2018 14

15. DEPRESSION AND AUTO
IMMUNITY9
CHRI, 2018 15

16. DELIRIUM & SLE
• Initially considered as most frequent (30%) complain
associated with SLE
• Currently seen only in 3% of patients with SLE
• LUPUS PSYCHOSIS – hours to days and completely subside
• Symptoms can be
• Mild confusion with clouding of consciousness
• More florid symptoms with visual and auditory
hallucinations CHRI, 2018 16

17. TREATMENT FOR NPSLE 10
Mild NPSLE – symptomatic treatment
New onset NPSLE or severe symptoms Immunosuppressant or
other therapy directed against autoimmunity.
Systemic gluco-corticoids show response in 60-75% patients.
Cyclophosphamide is the most common drug used for NPSLE.
11
Severe cases - addition of plasmapharesis as an adjuvant to
steroids or cyclophosphamide.
Rituximab (anti CD-20 monoclonal antibody) – refractory
NPSLE
CHRI, 2018 17

18. ANTI-NMDA
RECEPTOR
ENCEPHALITIS
• Initially, thought to be a
paraneoplastic disorder, occurring
in young females in association
with an ovarian teratoma .
• Later research suggested that It
can occur with or without a tumor,
and can arise in children and
young adults, both male and
female.
• Prevalence – around 1 % in ICU
admitted individuals of 18-
35years age group 11
DORSOLATERA
L PREFRONTAL
CORTEX
CHRI, 2018 18

19. 75 % pts present with psychiatric illness
Diagnosed with Acute psychosis / Mania with or
without psychotic symptoms/Drug abuse/
malingering
Treated with anti-psychotic
Mostly develop Features suggestive of NMS
On detailed Neurological examination and further
investigations
Diagnosed as ANTI-NMDA RECEPTOR ENCEPHALITIS
CHRI, 2018 19

20. PHASES OF ILLNESS 12
CHRI, 2018 20

21. DIAGNOSIS 12,13
• Elevated protein , oligoclonal
bands
• Lymphocytic pleocytosis.
• Anti-NMDA receptor antibody
CSF
• If abnormal, T2 or FLAIR
hyper intensities in cortical
or subcortical brain regions
MRI
•Usually abnormal
•Slow & disorganized
activity
EEG
TREATMENT 12,13
• Corticosteroids
• IV Immunoglobulin
• Plasmapharesis
• Underlying tumor –
Rituximab or
cyclophosphamide
• 75% - full
recovery/mild
deficits.
• 25% - severely
disabled / die .
CHRI, 2018 21

22. NMDA RECEPTOR & PSYCHOSIS
12,14
CHRI, 2018 22

23. AUTOIMMUNE
& PSYCHOSIS
Infectious
agents
Autoimmun
e
mechanisms
Development
al Two-hit
model
Inflammatio
n
hypothesis
Genetic link
CHRI, 2018 23

24. TREATMENT FOR PSYCHIATRIC
SYMPTOMS 12,14
Quetiapine as the initial drug for psychotic symptoms and
agitation
 Anti-cholinergics
 Benzodiazepines to manage sleep
 Trazadone
 Clonidine
Acutely agitated or psychotic patients who refuse medications
often respond well to Chlorpromazine.
ECT has also shown to be a safe and effective option
(particularly in catatonia)
CHRI, 2018 24

25. PSORIASIS Genetically primed
individuals
Unmyelinated
terminals of sensory
fibers in skin
Substance P & other
Neuropeptides
Local neurogenic
Inflammation
• Persistent skin disease
that causes rapid
turnover of skin cells
forming thick silvery
scales, itchy, dry and
red patches.
• Incidence – 1-2%
• Bimodal distribution
with early onset in
females.
NEUROGENIC INFLAMMATION HYPOTHESIS
OF PSORIASIS (FARBER Et.al) 15
CHRI, 2018 25

26.  Most prevalent Psychiatric
manifestations associated with
psoriasis 16
• Sexual disorders (71%)
• Sleep disorders (50%)
• Depression
• Anxiety
 Others include :
• Substance dependence or abuse
• somatoform disorders
• Schizophrenia/other psychoses
• Bipolar disorder
• Eating disorders
Psoriasis
Social stigma
Low self-
esteem
Poor
psychosocial
adjustment
Poor coping
mechanism
Worsen
other
Physical
conditions
CHRI, 2018 26

27. DEPRESSION & PSORIASIS
17,18
• High concentrations of
substance P
• Defect in β-adrenergic
function
• Low melatonin
secretion
• Raised pro-
inflammatory cytokines
CHRI, 2018 27

28. POSSIBLE ETIOLOGICAL FACTORS 16
SEXUAL DISORDERS SLEEP DISORDERS 20
Low self-esteem and
psychological factors
Depression
Pruritus Pain due to skin lesions
Psoriatic arthritis Obstructive sleep Apnea
Side-effects of psoriasis
treatment
Pruritus
Other psychiatric comorbidities Psoriatic Arthritis / Joint pain
Common symptoms seen
Decreased sexual desire
Anorgasmia
Erectile dysfunction
Early morning awakening
Increase in nocturnal awakening
Daytime sleepiness
CHRI, 2018 28

29. RHEUMATOID
ARTHRITIS
• More in women.
• 4-5th decade of life.
• Affects joints leading to
permanent deformations
• May present also with extra-
articular manifestations and
systemic complications
CHRI, 2018 29

30. Approximately one-fifth of patients with RA have a psychiatric
disorder and a similar number have subsyndromal psychiatric
symptoms. 21
Neuropsychiatric manifestations in RA can arise through any of the
following four processes 21
1. Direct CNS involvement
2. Secondary effects of the illness or its treatments
3. Emotional reactions to chronic illness
4. Comorbid primary psychiatric illness.
It is seen that, in most cases , psychiatric symptoms are due to
emotional reactions to having a painful potentially disabling and
immobilizing chronic illness adversely affecting work, family, social life,
and leisure activity. 22
CHRI, 2018 30

31. The frequency of depression and anxiety disorders among
patients with RA ranges from 14 - 42%. 22
Among female patients with RA who committed suicide, 90% had
a depressive disorder. 23
It was reported that RA Patients with depression complain
significantly higher levels of pain, greater number of painful joints,
and poorer functional ability
The main psychosocial factors, that cause negative adaptation are
include exposure to stressors , sleep disturbance , premorbid
anxiety.
Rarely they can manifest with dissociative disorders or psychotic
symptoms.
CHRI, 2018 31

32. ADDISON’S
DISEASE7
• Medical condition
characterized by chronic
adrenal insufficiency leading
to failure of glucocorticoid
secretion.
• 6-110 cases diagnosed per
100,000 in the world per year.
• Usually effects 30-50 year age
group. CHRI, 2018 32

33. EEG
Abnormality
•Bursts of 3-6sec of high voltage potentials with no definite cortical focus
•M/c - Diffuse slowing
Glucocorticoid
Deficiency
•Normally, cortisol binds to GC receptor in brain , modifying the gene transcription
•Deficiency causes memory impairment & cognitive changes and causes Neuroexcitability leading to enhanced ability
to detect sensory input (high tendency to develop hallucinations)
Increased
Endorphins
•POMC – rises ACTH and endorphin release.
•Elevated CSF endorphins – associated with Psychosis
Metabolic
Changes
•Hypoxia secondary to Hypotension – Changes in MSE
•Severe Hypoglycemia – Cogitive changes & coma
•Hyponatremia – Encephalopathy & brain damage
ETIOPATHOGENESIS 24
CHRI, 2018 33

34. NEUROPSYCHIATRIC MANIFESTATIONS
25
Seen in 64-84% of affected
individuals.
Common presentation -
•Depression
•Sleep disturbance
•lack of motivation
•Anxiety
•Agitation
•Memory impairment
Rare manifestations:
• Psychosis
• Self-mutiliation
• Severe cognitive disturbances
CHRI, 2018 34

35. MYASTHENIA
GRAVIS
• Chronic, autoimmune disease
caused by anti-cholinergic
antibodies that target
neuromuscular junctions
• Prevalence of about 20 per
1,00,000
• Unrecognized initially because
the psychiatric symptoms may
coincide with those of the actual
disease. CHRI, 2018 35

36. NEUROPSYCHIATRIC
MANIFESTATIONS 26
•20% patients – psychiatric symptoms
are the primary presentation
•40-50% patients experience
comorbid psychiatric illnesses.
•Depression & Adjustment disorders –
Most common
•Others- Insomnia; Memory
disturbances; Anxiety disorders;
Suicidality.
SLEEP DISORDERS 27
•Shorter REM sleep duration
•Increased number of
awakenings
•Reduced quality of sleep
•Increased dream recall
•Shallow Sleep EEG
MEMORY DISTURBANCES 28
•Poor performance in
•delayed recall memory
•verbal learning tests.
CHRI, 2018 36

37. ANTI-PHOSPHOLIPID SYNDROME
7,29
Similar to SLE
Primary APS – Most common acquired thrombophilia
The most common psychiatric symptom is cognitive impairment.
 Usually associated with the presence of vascular lesions in
white matter and are difficult to differentiate in MRI from
demyelination lesions seen in multiple sclerosis.
 May coexist with characteristic skin lesions called “livedo
reticularis”.
Other Psychiatric manifestations include – Depression ; Agression
and mania
CHRI, 2018 37

38. Sjogrens
Syndrome
•Mimic MS
•Anxiety(48%)
•Depression (32%)
Systemic sclerosis
•Neuropsychiatric
symptoms are
rare.
•Most common-
Depression (due
to chronic
illness)
Other
Autoimmune
•Type-1 DM
•Hashimoto’s
thyroiditis
OTHER AUTOIMMUNE DISORDERS
WITH PSYCHIATRIC MANIFESTATIONS 7,30
CHRI, 2018 38

39. •SSRI – preferred
•TCA and MAOI – to be cautious in
myasthenia & psoriasis
Antidepressa
nts
•Short acting BZDs are preferred
•Oxazepam ; lorazepam
Benzodiazepin
es
•Lithium – better
•Valproate & carbamazepine
Mood
Stabilizers
Anti-
psychotics
Haloperidol, amisulpride , Risperidone and
paliperidone – safer (To be monitored for EPS)
TREATMENT
CHRI, 2018 39

40. DEMYELINATING
DISORDERS
CHRI, 2018 40

41. INTRODUCTION
Demyelinating disorders have a common pathology, i.e., the
partial or complete loss of the myelin sheath surrounding axons
in the white matter of brain and spinal cord 31
It is often secondary to an infectious, ischemic, metabolic, or
hereditary disorder or to a toxin/alcohol.
In primary demyelinating disorders, autoimmune mechanism is
suspected as the pathogenesis.
As these axons are present throughout the brain and spinal
cord, lesions may occur diffusely, resulting in complex and
widespread neurological and psychiatric symptoms32
CHRI, 2018 41

42. CHRI, 2018 42

43.  27-year-old man with no prior psychiatric disorder or drug abuse was presented with 3
years history of
• Fear with the feeling of being followed by others, without any external stressor
• Hesitation and muttering, irritability, anger outbursts, bad tempering, and
antisocial behavior
• Thought his colleagues at work are likely to harm him due to his good skills at his
job.
• Depression, severe fatigue and loss of energy, loss of appetite, and weight loss
• Joint stiffness and loss of movement control at upper and lower limbs.
 After 6 months from the appearance of symptoms, he was brought to a psychiatric office
being uncertain of hallucinogenic drug abuse.
 The psychiatrist prescribed citalopram 20 mg OD, risperidone 2 mg TDS & Biperiden 2mg
TDS
 After a month of medications , due to no improvement in symptoms , patient was
referred to carry out MRI to rule out organic disorders.
 Gradually he developed paresthesia, upper and lower limb muscle weakness, ataxia, and
urinary incontinency.
 The T2-weighted MRI demonstrated periventricular and white matter multiple sclerotic
CASE VIGNETTE - 3
33
CHRI, 2018 43

44. MULTIPLE SCLEROSIS 34
Definition Chronic inflammatory disease in the CNS with a
progressive demyelination of nerve cells & damage in
sensory-motor pathway that cause specific
neurological and psychological symptoms.
Prevalence 5-9/1lakh population (India)
More common Women ; 20-50 years age
Diagnosis Presence of 2 attacks, involving different parts of the
CNS, separated by a period of at least 1 month &
lasting a minimum of 24 hours.
Lab
investigations
• CSF – atleast 2 oligoclonal bands or raised IgG
synthesis
• Evoked potentials (VEP & SSEP) – slowed or absent
MRI • T2-hyperintense lesions and gadolinium-enhancing
CHRI, 2018 44

45. PATHOGENESIS
CHRI, 2018 45

46. CHRI, 2018 46

47. COGNITIVE IMPAIRMENT & MS
Seen in 50-70 % patients
Components affected are
• Memory
• Information processing
• Executive functioning
• Attention & concentration (occupational impairment)
Intellectual & language functioning – relatively intact.
Minimal Assessment of Cognitive Function in MS
(MACFIMS)35
CHRI, 2018 47

48. Depressio
n in MS
As
prodrome
Co-
morbid
Side effect
of steroids/
IFN
As reaction
to chronic
MS
Due to MS
(same
etiology)
CHRI, 2018 48

49. DEPRESSION & MS 36,37
Lifetime prevalence – 50% of patients with MS.
Irritability more commonly seen than low self-esteem.
Neurobiology38 – Superior frontal or parietal regions , right temporal lobe
, left medial inferior prefrontal cortical lesions and dominant anterior
temporal atrophy
Factors that worsen the prognosis of illness:
• Suicidal tendency
• Functional disability
• Negative cognitions
 Treatment
• Not needed in around 60% patients.
• Low dose antidepressants ( Sertraline/ Desipramine) with CBT -
preferred CHRI, 2018 49

50. PSYCHOSIS & MS
33,39
Though rare (2-3%) , seen generally in the later stages of MS
Symptoms seen – somatic delusions; disorganized behavior; rarely
hallucinations (visual & auditory)
Affective psychosis more common when compared to schizophrenia.
Increased activation of inflammatory signaling pathways and altered anti-
inflammatory activity are common factors in the pathophysiology of MS and
psychotic disorders.
Seen in patients with periventricular involvement (temporal region)
Treatment – low dose atypical antipsychotics in combination with MS
treatment (steroids and IFN) with proper supervision
CHRI, 2018 50

51. ANXIETY
DISORDERS
40
•25-41%
•Females
•Most
common:
•GAD
•Panic
disorder
•OCD
BPAD4
1
• Presentation
as Mania
• 0.3%
• a/w lability of
affect (10%)
Other MOOD
abnormalities
42
• Euphoria (33%)
• Pseudo bulbar
Affect(10%)
• TCA / SSRI
• Levodopa &
dextromethorphan
-quinidine
combination.
Substance
Use
Disorders
•18.7%
•Alcohol43&
Cannabis44
– most
common
CHRI, 2018 51

52. • Mr. A, a 27-year-old single male , pure vegetarian presented to OPD with
following symptoms of 1 year duration.
• Forgetfulness for several weeks, followed by social withdrawal, paucity of speech,
decreased interest in routine and pleasurable activities and apathy ; stopped
going to his work and taking household responsibilities unlike his previous self.
His self-care deteriorated markedly, appetite decreased grossly and he lost 5–7 kg
weight in 4–5 months. His duration of sleep also increased.
• Patient was started on Tab. Olanzapine 5 mg/d considering the option of negative
symptoms of schizophrenia .
• Over the next 3–4 weeks, he perceived minimal improvement, but developed b/l
weakness of lower limbs resulting in limping and walking with support. He was
referred to neurology opd.
• On detailed examination and investigations, he was diagnosed with sub acute
CASE VIGNETTE – 445
CHRI, 2018 52

53. VITAMIN B12
DEFICIENCY
 Water-soluble essential vitamin, has a
vital role in DNA synthesis during cell
division.
 Linked with synthesis of neurotransmitters
46,47
 Psychiatric manifestations 48,49 of vitamin
B12 deficiency include
• Depression
• Apathy
• Irritability
• Dementia
• Catatonia
• Delirium
• Hallucinations CHRI, 2018 53

54. VITAMIN B12
DEFICIENCY47
POOR INTAKE
Chronic alcohol use
Vegetarian diet
MALABSORPTION:
Lack of Intrinsic Factor
Ileal malabsorption
Bacterial overgrowth
DEFECTIVE
TRANSPORT
(GENETIC):
Transcobalamin
deficiency.
CHRI, 2018 54

55. Around 28% patients with B12 deficiency manifest initially
with psychiatric manifestations
Prevalence of neuropsychiatric manifestations in patients
with Vit-B12 deficiency ranges from 10-20% , more common
in elderly.
Comorbid Psychiatric condition or psychiatric manifestation
due to Vitamin B12 deficiency – Both tend to improve
symptomatically with parenteral cobalamin.
CHRI, 2018 55

56. NEUROPSYCHIATRIC MANIFESTATIONS
OF VIT-B12 DEFICIENCY 48,49
Biochemical Basis – Defect in methylation process 50
DEPRESSION
(38%)
Predominant depressive cognitions,
anhedonia , easy fatigability and somatic
symptoms
PSYCHOSIS
(1-16%)
Prominent Schneiderian first rank
symptoms
(Thought alienation; 3rd person AH;
Somatic passivity; Delusion of persecution
& reference)
BPAD Classical Manic features
CHRI, 2018 56

57. ALZHIEMERS
Severe naming
problems Paraphasias
Ideomotor Apraxia
COMMONLY
IMPAIRED IN BOTH
GROUPS
Concentration
Abstraction
Visuo-spatial
orientation
Categorization
VIT-B12 DEFICIENCY
DEMENTIA
Frequent Psychotic
symptoms
Mild naming problems
CHRI, 2018 57

58. CENTRAL
PONTINE
MYELINOLYSIS
Common clinical
manifestations
• Spastic quadriparesis
• Dysarthria
• Pseudo bulbar palsy
• Altered mental status.
Severe cases - locked-in
syndrome or even death can
occur.
Lesion – Symmetrical Butterfly
shaped area of demyelination
within the central pons. 52
DEFINITION: Clinically heterogeneous,
demyelinating condition originally
thought to occur only in the central
pons 51
Risk factors: 52
• Hyponatremia for > 24 hours
• Over-correction of hyponatremia (> 25
mEq/L/day)
• Rapid correction (greater than 1–2 meq/hr)
• Alcoholism
• Malnutrition
• Liver disease CHRI, 2018 58

59. CHRI, 2018 59

60. Demyelination of ascending fibers of RAS in
pons
Disruption of RAS pathway to thalamic nuclei
Affects several NT pathways
Acute change in behavior
CHRI, 2018 60

61. PSYCHIATRIC MANIFESTATIONS
• Psychiatric manifestations with CPM are rare.
• If present, seen after 2 weeks of onset of motor symptoms
• Few symptoms seen with CPM53 are
 Emotional liability(crying)
 Formal thought disorder
 Delirium
 Confusion
 Personality change
 Hallucinations
 Delusions of persecution and reference
CHRI, 2018 61

62. METACHROMATIC
LEUKODYSTROPHY54
•MLD in adolescence or early adulthood presents as psychosis in 53
% individuals (Disorganized cognitive processes, delusions and
auditory hallucinations).
•Normally in Psychosis, gray matter ( limbic areas & temporal lobe)
affected; While in MLD, there is demyelination of frontal white
matter
•The neuropathalogical correlation in MLD suggests that psychosis
can result from dysfunctional connectivity between certain extra
frontal and subcortical structures with the frontal lobe.
•Other psychiatric complaints are very rare.
CHRI, 2018 62

63. TREATMENT FOR
NEUROPSYCHIATRIC
MANIFESTATIONS IN
DEMYELINATING DISORDERS
DEPRESSION
•CANMAT GUIDELINES prefer use of
anti-depressants in comorbid mood
disorders.55
•SSRI or SNRI – preferred drug
•TCA (Desipramine)
•MAOI (Moclobemide)
•ECT (can worsen neurocognition).
•Antidepressants with CBT
•To be monitored for SWITCH in the
BIPOLAR DISORDER56
Based on side-effect profile
•Lithium
•Anticonvulsants
•Atypical antipsychotics
High risk patients –
prophylactically addition of mood
stabilizer to be considered.
CHRI, 2018 63

64. ANXIETY57
•SSRI & SNRI –preferred
•Benzodiazepines –
used for short-term
PSYCHOSIS 58
More prone to develop EPS
Atypical antipsychotics – better risk
vs. benefit
Ziprasidone, risperidone, and
aripiprazole - First-line
CHRI, 2018 64

65. NEUROPSYCHIATRIC
ASPECTS DUE TO
TREATMENT CHRI, 2018 65

66. STEROIDS 59, 60
•Used for almost all autoimmune and
most of demyelinating disorders
•Psychiatric manifestations :
 Mild & reversible after
withdrawal or decreasing steroid
dose.
 Old age – High risk
•Affective disorders - Family history of
depression & Substance use
•Psychotic Disorder – SLE;
Hypoalbuminemia; Higher dose of
steroids;
•10% cases – Psychotropic medications
needed
Commonly seen are :
• Emotional liability
• Sleep Disturbances
• Hypomania
• Mania
• Depression
• Psychosis
• Delirium(older patients)
• Cognitive changes and
memory deficits
CHRI, 2018 66

67. Widely used in the treatment of
milder forms of SLE, RA and
Sjogrens syndrome
In SLE - added to steroid therapy
In RA - used along with NSAIDs
and DMARDs.
Neuropsychiatric symptoms:
 mild and transient.
 Headache and dizziness.
 Emotional disturbances,
agitation, insomnia,
nightmares, anxiety, fatigue.
 Psychotic symptoms are
relatively rare.
INTERFERON 63
Used as treatment for MS and
other demyelinating disorders.
Most commonly seen
psychiatric illness – Depression
(5-25%)
Others :
• Anxiety (1.5-4%)
• Mania(less than 1%)
• Psychosis (less than 1%)
CHRI, 2018 67

68. TAKE HOME POINTS
•Missing an autoimmune or demyelinating disorder as a psychiatric disorder
can, sometimes, have serious and fatal consequences.
•Prodromal cases or milder cases may continue to be treated as psychiatric
disorders and hence a high index of suspicion is required to diagnose these
disorders , particularly in those with positive family history of autoimmune
disorders.
•Basic knowledge of these conditions is necessary to think of them, in case of
atypical presentation or refractory cases.
•Most of them being chronic illnesses, mood and anxiety disorders are more
prevalent and psycho education and CBT helps in them.
•In case of psychotic conditions, Typical antipsychotics should preferably be
avoided in these conditions.
CHRI, 2018 68

69. TO SUSPECT AUTOIMMUNE /
DEMYELINATING DISORDER WHEN
•Fatigue or cognitive impairment out of proportion to the
mood symptoms or depression
•Atypical presentation
•Not responding to anti-depressants or anti-psychotics
•Presence of EPS with minimal dose of typical anti-
psychotics
•To monitor BP and electrolytes if we suspect any
autoimmune disorders
CHRI, 2018 69

70. OTHER DISORDERS
PANDAS
Neuromyelitis optica
WILSONS disease
Celiac disease
CHRI, 2018 70

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