Are the Diagnosis and Treatment of Neuropsychiatric Comorbidity in Multiple Sclerosis Still in Their Infancy?
Are the Diagnosis and Treatment of Neuropsychiatric Comorbidity in Multiple Sclerosis Still in Their Infancy?
European Neurological Review - Volume 3 - Issue I
Four clinical dimensions can be impaired in multiple sclerosis (MS): neurological function, cognition, emotions, and fatigue. Neurological impairment, cognitive deficits, and fatigue are recognized to be part of the functional handicap and deterioration of quality of life in MS patients, while the effect of emotional impairment, which includes behavioral changes and decision-making difficulties, has been less precisely defined. In this context, neuropsychiatric comorbidity secondary to MS is becoming an important issue in MS medical care, and therapeutic efforts strongly depend on these dimensions. Moreover, the chronic aspect of the disease, individual socio-demographic situations, and the pre-morbid characteristics of each subject, as well as the brain impairment itself, influence neuropsychiatric symptoms in MS and interact with one another. Hence, it is not a surprise that subjective quality of life in MS is dependent on all of these dimensions: for example, suicidal intent of MS patients is related not only to disease-induced mood disorders such as depression, but also to the lifestyle modifications induced by MS such as alcohol abuse and individual habits such as living alone. In addition, other medical parameters such as the MS therapy itself and biographical factors such as coping abilities may influence the ability to cope with and react to such neuropsychiatric symptoms.
In this article we will present some features of these different dimensions and propose diagnostic and therapeutic cures, the latter (both pharmacological and non-pharmacological) being promising but still in their infancy. However, the most effective treatment of neuropsychiatric symptoms at the moment is early causal MS therapy.
Fatigue, cognitive deficits, mood disorders, and affective changes are now recognized as frequent in early MS. It is crucial to differentiate the prevalence of subtle neuropsychiatric alterations in prospective cohort studies from clinically significant impairment, which must be diagnosed in clinical practice. However, prospective studies have shed light on the frequency and potentially devastating effect of such comorbidities, and have thus provided a rationale for efficient screening in everyday practice. We will focus separately on the different groups of symptoms in order to outline an operational approach to each of them.
Fatigue is a multidimensional, motor-perceptive, emotional, and cognitive experience, and in this sense it is highly representative of the neuropsychiatric symptoms found in MS. It can be independent of depression, but correlates highly with mood disorders, decreased levels of action control, and motivational disturbances.1 Objective fatigue-related factors (i.e. “observable and measurable decrement in performance occurring during the repetition of a physical or mental task”) can be dissociated from subjective fatigue, which is characterized by “a feeling of early exhaustion, weariness, and aversion to efforts” similar to (although different from) neurasthenia, as defined by the 10th International Classification of Diseases (ICD-10). Moreover, in many ways fatigue in MS is qualitatively different from fatigue as experienced by stroke patients. It is characteristically relieved by rest and has a strong psychological impact.2
It is not surprising, given the diversity of manifestations of this symptom in MS, that evidence-based therapy for fatigue has been very disappointing, and most clinicians agree that the most successful approach is to adapt the activities of patients. However, there seem to be some pharmacological and non-pharmacological ways to alleviate fatigue symptoms. For example, clinical experience and systematic findings from some small series have suggested that a variety of symptomatic approaches—such as dopaminergic wake-promoting agents (e.g. methylphenidate or modafinil)—but also physical training, yoga,3 or acting on secondary causes—such as reduction of neurogenic pain, management of sleep difficulties, and treatment of depression—may have some beneficial effects in the treatment of fatigue. The challenge before editing guidelines to reflect this is a precise characterization of the type of fatigue for each MS patient.
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