Case report: "Purely" psychiatric presentation of multiple sclerosis in an adolescent boy

"My sister wants to kill me": A case report and systematic review of literature of co-occurring multiple sclerosis and psychosis

Background

Multiple sclerosis (MS) is a neurological disorder with demyelination of neuronal matter, especially of white matter, with multiple episodes occurring temporally. It has been associated with multiple neurological and psychiatric sequelae. Depression and other affective symptoms are commonly associated with MS. Previous research has also suggested that psychotic symptoms may co-occur with MS as well.

Material and Methods

A case report was prepared on the patient admitted to the inpatient unit. Subsequently, a systematic literature review of literature was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model on three databases. Search terms included (MS OR multiple sclerosis) AND (Psychosis OR schizophrenia OR schizoaffective disorder OR psychotic OR hallucination OR delusion).

Results

The literature review led to an initial discovery of 2711 hits on PubMed, 1276 hits on PsycINFO, and 5429 hits on Embase. Some patients were diagnosed with MS at an earlier age with a later onset of psychosis, while some were initially diagnosed with psychosis (or schizophrenia) first and subsequently with MS. Psychotic symptoms observed included persecutory delusions, lack of insight, delusions of reference, auditory hallucinations, grandiose delusions, and passivity. The commonly prescribed antipsychotics included risperidone, olanzapine, quetiapine, and aripiprazole. The presence of co-occurring psychosis in MS patients underscores the need for a comprehensive evaluation of symptoms.

Conclusion

This case highlights the importance of conducting a magnetic resonance imaging (MRI) brain not only for initial onset psychosis but also for any sudden changes in patients who have had a relatively stable course. Moreover, psychosis can affect treatment adherence in MS, making it all the more critical to identify and manage it promptly.

Outcome of psychiatric symptoms presenting at onset of multiple sclerosis: a retrospective study

Psychiatric disturbances may occur at the onset of multiple sclerosis. However, information on their outcome is lacking. Our objective was to document the characteristics of psychiatric symptoms at presentation of multiple sclerosis and to define the long-term evolution of psychiatric disturbances in these patients. Based on a clinical record analysis of patients with defined multiple sclerosis diagnosis and coming under the care of a university multiple sclerosis centre within the period 1997-2007, patients with both psychiatric and neurological symptoms at presentation were identified. Clinical data at onset and at last follow-up were considered. Among 682 evaluated patients, psychiatric disturbances were associated with multiple sclerosis onset in 16 cases (2.3%). Most patients (56%) presented with a mood disorder with clinical characteristics of a major depressive-like episode, five (32%) had psychotic symptoms. Initial psychiatric disturbances improved later than neurological symptoms, or never fully recovered, regardless of the concomitant use of psychotropic medications. In most of the subjects psychiatric disturbances tended to remain over the follow-up period and at last visit, after a mean follow-up of 7.6 years (+/-2.3), 14 subjects (87%) had a supplementary diagnosis of psychiatric illness. Psychiatric symptoms at onset of multiple sclerosis may be indicators of possible maintenance of psychiatric morbidity in a sizeable proportion of patients.