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Multiple Sclerosis
Are the Diagnosis and Treatment of Neuropsychiatric Comorbidity in
Multiple Sclerosis Still in Their Infancy?
a report by
Jean-Marie Annoni, MD,
1,2
Myriam Schluep, MD
2
and Pasquale Calabrese, MD, PhD
3
1. Department of Neurology, and Medical School, Geneva University Hospitals; 2. Centre Hospitalier Universitaire Vaudois, Lausanne;
3. Department of Neurology, Bochum University Hospital
Four clinical dimensions can be impaired in multiple sclerosis (MS): dissociated from subjective fatigue, which is characterized by “a feeling of
neurological function, cognition, emotions, and fatigue. Neurological early exhaustion, weariness, and aversion to efforts” similar to (although
impairment, cognitive deficits, and fatigue are recognized to be part of different from) neurasthenia, as defined by the 10th International
the functional handicap and deterioration of quality of life in MS patients, Classification of Diseases (ICD-10). Moreover, in many ways fatigue in MS
while the effect of emotional impairment, which includes behavioral is qualitatively different from fatigue as experienced by stroke patients. It is
changes and decision-making difficulties, has been less precisely defined. characteristically relieved by rest and has a strong psychological impact.
2
In this context, neuropsychiatric comorbidity secondary to MS is becoming
an important issue in MS medical care, and therapeutic efforts strongly It is not surprising, given the diversity of manifestations of this symptom in
depend on these dimensions. Moreover, the chronic aspect of the disease, MS, that evidence-based therapy for fatigue has been very disappointing,
individual socio-demographic situations, and the pre-morbid and most clinicians agree that the most successful approach is to adapt the
characteristics of each subject, as well as the brain impairment itself, activities of patients. However, there seem to be some pharmacological and
influence neuropsychiatric symptoms in MS and interact with one another. non-pharmacological ways to alleviate fatigue symptoms. For example,
Hence, it is not a surprise that subjective quality of life in MS is dependent clinical experience and systematic findings from some small series have
on all of these dimensions: for example, suicidal intent of MS patients is suggested that a variety of symptomatic approaches—such as dopaminergic
related not only to disease-induced mood disorders such as depression, wake-promoting agents (e.g. methylphenidate or modafinil)—but also
but also to the lifestyle modifications induced by MS such as alcohol abuse physical training, yoga,
3
or acting on secondary causes—such as reduction
and individual habits such as living alone. In addition, other medical of neurogenic pain, management of sleep difficulties, and treatment of
parameters such as the MS therapy itself and biographical factors such as depression—may have some beneficial effects in the treatment of fatigue.
coping abilities may influence the ability to cope with and react to such The challenge before editing guidelines to reflect this is a precise
neuropsychiatric symptoms. characterization of the type of fatigue for each MS patient.
In this article we will present some features of these different dimensions Cognitive deficits have been estimated to occur in up to 70% of patients
and propose diagnostic and therapeutic cures, the latter (both during the course of MS. They may also be the primary cause of secondary
pharmacological and non-pharmacological) being promising but still in behavioral and emotional alterations. One example is the influence of
their infancy. However, the most effective treatment of neuropsychiatric impaired working memory on the ability to cope with stressful, complex
symptoms at the moment is early causal MS therapy. situations. Cognitive dysfunctions may encompass a variety of functions,
including long-term and working memory, interhemispheric transfer
Fatigue, cognitive deficits, mood disorders, and affective changes are now (which may lead to alexithymia), problem-solving, executive functions,
recognized as frequent in early MS. It is crucial to differentiate the information processing speed, and attention.
prevalence of subtle neuropsychiatric alterations in prospective cohort
studies from clinically significant impairment, which must be diagnosed in While the clinical profile of MS-related cognitive disturbances is
clinical practice. However, prospective studies have shed light on the characterized by a subcortical type of impairment, affecting mainly
frequency and potentially devastating effect of such comorbidities, and memory and executive functions, the range of neuropsychological deficits
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.
Jean-Marie Annoni, MD, is an Associate Professor of Neurology
and Head of the Neuropsychological Unit in the Neurological
Department of Geneva University Hospitals, and an Associate
Fatigue is a multidimensional, motor-perceptive, emotional, and cognitive
Neurologist in the Neurological Department of the Centre
experience, and in this sense it is highly representative of the
Hospitalier Universitaire Valdois in Lausanne; he has clinical and
academic activities in both hospitals. He has a particular interest
neuropsychiatric symptoms found in MS. It can be independent of
in behavioral neurology; his main interests are in the field of
depression, but correlates highly with mood disorders, decreased levels
language and cognition, but he has also developed expertise in
of action control, and motivational disturbances.
1
Objective fatigue-related
behavioral modifications associated with multiple sclerosis.
factors (i.e. “observable and measurable decrement in performance
E: Jean-Marie.Annoni@hcuge
occurring during the repetition of a physical or mental task”) can be
© TOUCH BRIEFINGS 2008
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