Psychiatric aspects of Behcet's syndrome

The burden of mental health issues in Behçet's disease: implications for patient quality of life

INTRODUCTION

Depression and anxiety are among the most prevalent mental health conditions in Brazil. Both are associated with poor quality of life (HRQoL) and challenges in disease management for chronic illnesses, including Behçet's disease (BD). This study aimed to evaluate depression, anxiety, and HRQoL in BD patients from a non-endemic area.

RESEARCH DESIGN AND METHODS

This case-control study included adult BD patients from Brazilian tertiary center and healthy controls (HC). All patients fulfilled the ISG and ICBD diagnostic criteria. Depression, anxiety and quality of life were assessed using BDI, HADS, SF-36, and physical capacity with the HAQ.

RESULTS

We enrolled 58 BD patients (60% female, mean age 46.1) and 96 HC (74% female, mean age 44). High rates of depression and anxiety were observed in BD patients, correlating with disease activity, younger age, absence of a partner, shorter disease duration, and lower income. BD patients showed significant HRQoL restrictions, particularly in physical and emotional roles, compared to HC. Longer disease duration was correlated with better HRQoL.

CONCLUSION

High rates of depression and anxiety were observed in BD patients, negatively impacting HRQoL, particularly in those with higher disease activity. Further study and clinical attention are warranted to enhance patient care and outcomes.

Psychiatric Symptoms and Cognitive Disorders in Behçet's Disease: A Single-Center, Cross-Sectional Study

BACKGROUND

Behçet's disease (BD) is a rare form of vasculitis involving both veins and arteries of all calibers. Psychological symptoms and cognitive impairment appear to be frequent, but few data are available.

METHODS

All consecutive patients in our center fulfilling the 2013 BD criteria underwent a psychometric evaluation with auto- (SCL-90-R and Modified Fatigue Index) and hetero-questionnaires (MINI). A standardized test battery assessed cognitive dysfunction. Data were correlated with BD activity as well as quality of life (SF-36).

RESULTS

We included 20 consecutive patients (16 men, four women) with a median [IQR] age of 38 (30.0-45.5) and a median disease duration of 7 years (1.8-11.0). Five patients had an abnormal brain MRI. The SCL-90-R questionnaire highlighted eight psychopathological profiles (42.1%) that correlated with altered quality of life and more severe fatigue. The most frequent symptoms were anxiety (9/19, 47.4%), somatization (8/19, 42.1%) and phobia (5/19, 26.3%). Psychopathological symptoms appeared to be more severe, but not more frequent, in neuro-Behçet's patients. Based on standardized cognitive evaluation, nine patients had cognitive impairment defined by three or more altered tests. Notably, 6/9 patients did not have any complaint of memory loss and were thus considered ansognostic.

CONCLUSION

Cognitive involvement was significantly associated with BD activity score (BSAS) but not with brain MRI abnormalities.

Safety of systemic treatments for Behçet's syndrome

INTRODUCTION

Treatment of Behçet's syndrome (BS) is aimed at controlling all symptoms of such a complex disorder, ensuring a good quality of life and preventing life-threatening complications. A better understanding of the pathogenic role of different chemokines has improved our knowledge of BS and elicited a more specific use of therapies currently available, minimizing the burden of potential side-effects related to treatment.

AREAS COVERED

This work aims to provide a detailed overview of the safety profile for current therapies available in the treatment of BS, focusing on the main side-effects, toxicity and contraindications.

EXPERT OPINION

The greatest experience in the management of BS has been achieved with the employment of monoclonal anti-tumor necrosis factor antibodies which have been advocated for BS refractory manifestations. Moreover, interleukin-1 inhibitors have proven to be effective as well as safe, despite escalation of their dosage, especially to manage the most severe and difficult-to-treat ocular manifestations. However, general treatment of BS patients remains awkward as protean clinical features may respond differently to the same treatment or even worsen. Therefore, patients' safety for therapies used in BS promotes the implementation of precision medicine, which could help targeting accurately the pathogenetic mechanisms concealed behind specific clinical phenotypes.

Chronic behavior disturbance and neurocognitive deficits in neuro-Behcet's disease: a case study

Behcet's disease is a vasculitis and multisystem inflammatory syndrome. Neurological abnormalities occur in a subset of patients. This report presents a case of neuro-Behcet's disease characterized by an initial onset of behavior changes prior to diagnosis, which evolved into a chronic behavioral syndrome. Neuroimaging investigations revealed progressive periventricular white matter and brainstem atrophy and lesions in the basal ganglia and deep white matter tracts, while neuropsychological investigations revealed reductions in information processing, executive functioning, and memory. The case indicates that behavior changes may be the first symptoms to emerge in Behcet's, before other defining features of the disease.

Epidemiology and management of neuropsychiatric disorders in Behçet's syndrome

Behçet's syndrome (BS) is a systemic, chronic, relapsing vasculitis, typically characterized by recurrent orogenital ulcers, ocular inflammation and skin manifestations; articular, vascular, gastroenteric and neurological involvement may also occur. Besides the other clinical features of BS, it seems relatively frequent that patients with BS develop a neurobehavioural syndrome, characterized by euphoria, bipolar disorders and paranoid attitudes, loss of insight/disinhibition, and indifference to their disease, defined as 'neuro-psycho-BS'. To date, the pathogenetic mechanism underlying neuro-psycho-BS has not been determined. It may be secondary to organic neurological involvement, or it may be related to poor quality of life and the relapsing course of the disease. Another engaging theory suggests that it could be related to the frequent observation of psychiatric symptoms during relapses or, in some cases, in the phases preceding reactivation of the disease; these elements suggest that psychiatric disorders in BS could represent a crucial element, whether a psychiatric subset or a distinct clinical feature of the disease. Moreover, it has been reported that cognitive impairment in BS can be seen with or without central nervous system involvement. Globally, psychiatric symptoms have been described as being multifaceted, ranging from anxiety disorders to depressive-bipolar disorders or to psychotic ones. In addition, some psychological characteristics of BS patients seem to predispose them to maladaptive stress management, which may lead to stress-related disorders, including anxiety and depression. Therefore, the aims of this review are to explore the epidemiology of neuro-psycho-BS by evaluating the relationship between the stress system and the multifaceted psychiatric manifestations in BS, and to summarize the therapeutic strategy used.

The effect of Behçet's disease on sexual function and psychiatric status of premenopausal women

INTRODUCTION

Little is known about the relationship between Behçet's disease (BD) and female sexual dysfunction (FSD).

AIMS

The aims were to evaluate the prevalence of FSD in premenopausal BD patients and to compare hormonal and psychiatric conditions to healthy subjects.

METHODS

A total of 71 married women with BD and 63 healthy married women between 18 and 44 years old were enrolled into the study. After evaluating detailed history and physical examination, serum steroid hormone levels were measured. Presence of genital ulcerations in physical examination and any medical treatment were recorded in patients. All subjects were asked to complete the Female Sexual Function Index (FSFI) for sexual status and Beck Depression Inventory (BDI) for psychiatric assessment.

MAIN OUTCOMES MEASURES

FSFI and BDI scores and serum sex steroid hormone levels were measured in women with BD and healthy controls.

RESULTS

The mean BDI score of patients was significantly greater than that for controls (P = 0.001), and there was a statistically significant difference between BDI scores (Pearson chi2 = 19.109, P = 0.001). FSD was found in 34 patients with BD (47.9%) and in 11 controls (17.5%). A statistically significant difference was found between the two groups (Pearson chi2 = 13.855, P = 0.001). While the most common sexual problem in the patients with BD was diminished arousal (n = 49, 69.0%), diminished desire was found in 32 patients (45.1%) and lubrication problems in 36 patients (50.7%). There was a statistically significant negative correlation between BDI and FSFI score in BD patients. On the contrary, there was no relationship between FSFI and presence of genital ulcerations.

CONCLUSION

FSD is more common in BD patients than in healthy subjects. We conclude that depressive mood according to the BDI scale correlates with the sexual status of BD patients, and this may be because of the depressive effect of BD as a chronic disease.

Psychiatric disorders in patients with Behçet's disease

Objective. In this study, we aimed to investigate current prevalence and related clinical factors of psychiatric disorders in Behçet patients. Methods. Seventy-three outpatients who applied to a Behçet clinic and whose diagnosis was Behçet's disease according to criteria of the International Study Group for Behçet's disease were recruited in this study. Psychiatric diagnoses were assessed with The Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV). Results. Thirty patients (41.1%) reported at least one current psychiatric disorder. Major depression (17.8%) was the most frequent psychiatric disorder. Specific phobia (16.4%), generalized anxiety disorder (15.1%) and social phobia (9.6%) were other frequent disorders. Prevalence rates of any psychiatric and anxiety disorder were significantly higher in females than males. There was no significant relationship between psychiatric morbidity and clinical characteristics of Behçet's disease. Conclusion. Our study suggests that Behçet patients have high prevalence of psychiatric disorders. Therefore, psychiatric evaluation should be performed in all patients with Behçet's disease.

Executive dysfunctions and depression in Behçet's disease without explicit neurological involvement

This study aims to assess the executive functions and depression status in patients with Behçet's disease without explicit neurological involvement and to evaluate cognitive functions in this group of patients independent of accompanying depression. In the present study, 30 patients with Behçet's disease in the non-active phase of their illness and 30 healthy volunteers were included. In the evaluation of depression levels, Beck Depression Inventory was employed. The executive functions of the patients were evaluated by Wisconsin Card Sorting Test (WCST) and Stroop Test (ST). Beck Depression Inventory scores measured in the Behçet's disease group, in which no clinically serious depression was observed, were higher than the control group. Then, it was observed that the scores of neuropsychological tests of the Behçet's disease group were found to be significantly lower, especially in WCST, while significant relations were revealed between Beck Depression Inventory scores and WCST, ST scores. The authors' findings suggest that there may be factors other than depression causing executive impairment in patients with Behçet's disease without explicit neurological symptoms. Executive dysfunctions may occur in association with mild depressive states due to chronic disease stress or silent and/or future neurological involvement of Behçet's disease, especially in the frontal lobes.

Trouble psychotique aigu et maladie de Behçet : à propos d’un cas

BACKGROUND

Behçet's disease is a multisystem vasculitis of unknown origin. The prevalence of the disease varies widely and is high in the Eastern Mediterranean Basin, North Africa, Iran and Japan. Many clinical features of Behçet's disease have been described and the international study group for Behçet's disease has defined a set of diagnostic criteria. These require the presence of recurrent oral ulcers plus two of the following: recurrent genital ulcerations, typical defined eye lesions, typical defined skin lesions or a positive pathergy test (a skin hypersensitivity reaction to a non-specific physical insult; when positive, the response consists of a papule or pustule that develops after 24 to 48 hours at the site of a needle prick to the skin). Although not included in these diagnostic criteria, there are some other features commonly seen in patients with Behçet's disease: thrombophlebitis, oligo-arthritis, gastrointestinal ulcerations and neurological involvement. Neuro-Behçet is well described in Behçet's disease, with variable prevalence rates between 5.3 and 35%. This prevalence is probably affected by the type of study (retrospective or prospective) and regional and ethnic variations in disease expression. Psychiatric symptoms usually occur as incidental findings in some patients with neurological disease; they are misdiagnosed and mistreated.

CASE-REPORT

The patient described here developed acute psychotic symptoms without parenchymal cerebral involvement, and negative symptoms during Behçet's disease. Two hypotheses were evoked: schizophrenia associated with Behçet's disease versus psychiatric syndrome induced by vasculitis. Such a case has not been reported in the literature. We describe the case of a 31-year-old Haitian female, admitted because of an acute psychosis. She developed hallucination, misrecognition, psychomotor hyperactivity and delusion about her million childbirths. The patient had three years history of mistreated Behçet's disease, in particular recurrent oral ulcers, iritis and cardiovascular manifestations. She also had a history of uterine tumour, rectal carcinoid tumour and recurrent pleurisies. One year ago, she presented breast lymphangitis, anxiety, unusual thought content, hostility, suspiciousness, and poor impulse control: cranial computerised tomography scan was normal. After ten days of hospitalization, she complained of oral and genital aphta and no neurological sign was found. The cerebral angiographic magnetic resonance imaging showed a thrombophlebitis of the left lateral sinus without parenchymal involvement. Haloperidol, Heparin, Colchicine, Cyclophosphamide and Prednisone were introduced. Six months after, delirium and Behçet's symptoms had disappeared with the following treatment: Risperidone, Alprazolam, Zolpidem, Colchicine, Prednisone, and Azathioprine. The patient has developed enduring negative symptoms: blunted affect, social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation and poor rapport. They are still present. This patient had two acute psychotic symptoms without parenchymal pattern. After treatment, she had persistent negative symptoms and psychosocial deterioration. This evolution is commonly seen in schizophrenia.

DISCUSSION

Retrospective analysis of this patient's course suggests that -psychiatric episodes were always associated with physical manifestations. However, pleurisies, lymphangitis, uterine and rectal tumours have never been described in Behçet's disease. This vasculitis occurs less frequently in the Caribbean than in Mediterranean, Middle East or Japan. It seemed that this patient had a psychotic syndrome and a chronic relapsing multisystem disorder, more complex than Behçet's disease. A prospective study would be useful to characterize psychiatric patterns of Behçet's disease and establish their relationships with physical manifestations, especially neurological involvement.

Resistant bipolar disorder precipitated by Behcet's syndrome

OBJECTIVE

To report a case of a patient with Behcet's syndrome who developed treatment resistant bipolar disorder (BD) several years after the onset of Behcet's syndrome.

METHODS

A 62-year-old woman suffering from Behcet's syndrome since the age of 38, who developed a typical BD 6 years after the first manifestations of the syndrome was described.

RESULTS

Once BD occurred, Behcet's syndrome became milder, while BD deteriorated and evolved into a rapid cycling illness. Lithium and carbamazepine were ineffective in controlling the affective symptoms, while sodium valproate combined with low doses of carbamazepine and olanzapine resulted in sufficient stabilization of her mood state.

CONCLUSIONS

Behcet's syndrome may have been the organic substrate for BD in this case. The appearance of BD in the setting of an organic-immune disorder, like Behcet's syndrome, suggests that such disorders may be the neurobiologic substrate or contributor for BD, at least in certain cases.

Stressful life events, anxiety, depression and coping mechanisms in patients with Behçet's disease

BACKGROUND

Behçet's disease is a systemic immunoinflammatory disease of young adults characterized by systemic vasculitis of arteries and veins. Although many studies have been published since its discovery in 1937, the etiopathogenesis of this unique disorder is still unclear.

OBJECTIVE

To assess the relationship between stress factors, psychological and somatic symptoms, and coping mechanisms in patients with Behcet's disease.

METHOD

Thirty-four patients with Behcet's disease and 43 control subjects were compared by using sociodemographic data collection forms, a psychosocial and environmental problems list, the Beck Anxiety Inventory (BAI), Hamilton Depression Rating Scale (HAM-D) and Toronto Alexithymia Scale (TAS).

RESULTS

Twenty-four patients (70.6%) defined stress factors in the first stage of the disease. Twenty-seven (79.4%) out of 34 patients stated that the recurrence period of the disease was related to the stress factors. Fear was expressed by 10 (29.4%) patients, sadness by 11 (32.3%), and fear plus sadness by 13 (38.2%) when they first learnt the diagnosis. While coping with these emotions 14 (41.2%) revealed active-reliance strategy. A statistically significant difference was present between the Behcet's patients and control subjects regarding TAS (P < 0.05), HAM-D (P < 0.001) and BAI (P < 0.001) scores.

CONCLUSION

It seems that stressful life events have important implications in both relapsing and remission periods of Behçet's disease via secondary problems.

Depression, anxiety levels and general psychological profile in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem disease with unknown etiology. Until today, the role of emotional stress and the real incidence of psychiatric symptoms in this disease have not been clarified yet.

OBJECTIVE

In this study, we aimed to evaluate the general psychological profile of the patients diagnosed as having BD as well as their depression and anxiety levels in order to investigate the psychiatric aspects of this disease.

MATERIAL AND METHODS

Twenty-three patients with BD and 17 patients with chronic plaque-type psoriasis who made up the control group were examined by the Beck Depression (BDI), Beck Anxiety (BAI) and Brief Symptom Inventories (BSI).

RESULTS

The mean BDI score of the BD group was 11.69 +/- 6.93, and the corresponding value was 9.11 +/- 7.34 for the psoriasis group. The mean BAI score of the BD group was 21.39 + 13.68 and this level was 12.41 +/- 10.70 for psoriasis patients. The mean BSI score of the BD group was 61.30 +/- 43.66 and it was 30.41 +/- 28.77 for the control group. The mean BDI, BAI and BSI scores of the patients diagnosed as having BD were significantly higher than those of the control group (F = 0.234, F = 0.508, F = 0.549 and p < 0.05).

CONCLUSION

BDI, BAI and BSI scales are useful to evaluate the psychiatric aspects of BD. The results of our study revealed that the collaboration of a dermatologist and psychiatrist is essential for the follow-up of patients with BD.

Behçet's disease and complex aphthosis

Behçet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behçet's disease. Although the pathogenesis of both Behçet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.

Behçet's disease in Kuwait, Arabia. A report of 29 cases and a review

Twenty-nine patients with Behçet's disease were studied. Of these, 17 patients were followed up for a mean duration of 37 months and 12 for a mean of 18 months. Male to female ratio was 3.1:1. Of the 29 patients, 26 were Arab, 2 Asian and 1 Black African. The prevalence in the country was 2.1:100,000 population, in Kuwaitis 1.58:100,000, in non-Kuwaiti Arabs, 2.9:100,000 and in non-Arabs, 1.35:100,000 population. The frequencies of the various manifestations were: oral ulcers, 100%; genital ulcers, 93%; skin manifestations, 76%; arthropathy and ocular disease, 69% each; psychiatric disorders, 38%; vascular complications and positive Pathergy test, 34% each; gastrointestinal symptoms, 21%; oesophageal and CNS involvement, 14% each; and peritonism, renal and pulmonary involvement, 7% each. Kuwaiti bedouins seemed to be resistant to the disease, probably due to environmental and/or dietary factors. The hot arid climate of the Gulf had no effect on the course of the disease once it had developed.

Behçet's disease

Behçet's disease is characterized by three primary components: iridocyclitis (historically with hypopyon), aphthous lesions in the mouth, and ulceration of the genitalia. Erythema nodosum, arthropathy and thrombophlebitis often accompany these manifestations, but the ocular symptoms may be the most important and serious manifestations of the disease. Central nervous system involvement, most often due to necrotizing vasculitis, may be the most protean manifestation of the disease, leading to death. The frequency of ocular manifestations is 70-85% in patients with the disease; the underlying disease mechanism in all organ systems is an occlusive vasculitis. Although the most common ocular symptom is that of anterior uveitis, often with hypopyon as a very late sign, the presence of necrotizing retinal vascular lesions is well known and often obscured by the severity of the anterior reaction. Definitions, incidence, clinical characteristics, differential diagnosis, and management of Behçet's ocular disease are discussed, as are the interrelationships of the different organ manifestations. The ophthalmologist should be familiar with the full spectrum of disease presentation since he or she may be the first physician to encounter the Behçet's patient.

Behçet's syndrome: a family study and the elucidation of a genetic role

A family with features of the mucocutaneous ocular syndrome is described. A 4-generation study reveals that the condition has been inherited as an autosomal dominant trait with variable expressivity. Psychiatric symptoms and myalgia have been prominent features peculiar to our patients.

Behcet's syndrome in 32 patients in Yorkshire

Thirty-two patients with Behcet's syndrome were surveyed clinically, radiologically, and immunologically. HLA antigens were determined in a proportion. The patients were culled from a defined geographical area (Yorkshire) with a population of 5 million. 21 patients satisfied Mason and Barnes's (1969) criteria for major disease. 100% had mouth ulceration, 91% genital ulceration, 66% skin complaints, and 63% arthritis (of the nonerosive type previously documented). 3 patients had gastrointestinal involvement, one of whom had proven Crohn's disease. One patient had psoriasis. One patient had a popliteal artery aneurysm resected and one has since had surgery after the development of a tracheo-osophageal fistula. No sacroilititis was found.

Familial Behçet's syndrome

Behçet's syndrome is reported in a family of which four generations have so far been affected. The index patient also exhibited an unusual schizo-affective disorder. The histocompatibility antigen haplotype 1-17 was common to four with the disease. Genetic transmission may be responsible for the familial nature of the syndrome and the associated schizophrenia.