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Pollianna
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Hope it's ok to post this. it seems to be a very good report

[Psychiatric manifestations of lupus erythematosus systemic and Sjogren's syndrome]
[Article in French]

Ampélas JF, Wattiaux MJ, Van Amerongen AP.

Service ERIC (Docteur Robin), Hôpital Charcot, 30, rue Marc-Laurent, 78373 Plaisir.

We present one case of Sjögren's syndrome (SS) secondary to systemic lupus erythematosus (SLE) with predominant psychiatric manifestations, treated with success by cyclophosphamide. From this case, we review the psychiatric aspects of these two autoimmune diseases as described in the literature and we present the etiopathogenic hypothesis and treatment of the psychiatric disorders.

Case report--In August 1996, a 38 year old man was admitted in our psychiatric department for agitation. Primary SS had been diagnosed in July 1996. He had previously attempted to suicide but was never hospitalized in a psychiatric department. During the hospitalization in our department, the patient had auditive hallucinations and felt persecuted. He received loxapine 400 mg/day and was remitted in a few days. He was discharged to a convalescent home with the diagnosis of brief psychotic disorder.

In October 1996, he was readmitted to our department for agitation. He had shown agitated behavior and aggression in the convalescent home. There were no hallucinations and no affective disorders. He became calm rapidly and was discharged home a few days later. In November 1996, he was found in a coma by a neighbor. He was admitted to an intensive care unit. The lumbar punction revealed blood cells. Cerebral computer tomography showed subarachnoid hemorrhage. The diagnosis was meningeal hemorrhage due to vasculitis. After regaining consciousness, the patient complained of reduced visual acuity. This was believed to be due to retrobulbar neuritis and the patient's vision improved slightly with corticosteroids.

The third hospitalization in our department occurred in February 1997 for depression. The patient had shut himself away for days in his apartment. He had suicidal ideas. His mood improved progressively under fluoxetine 40 mg/day. He was discharged to a convalescent home with the diagnosis of major depressive disorder.

The fourth and last admission in our department occurred in June 1997. There were disturbances of memory and orientation. He felt sad and guilty about accusation of sexual abuse on his daughter. He presented typical histrionic symptoms: he had catatonic attitudes only in public areas such as the corridors. Cerebral computer tomography and electroencephalogram were normal. There was no biological abnormality. Signs of confusion rapidly disappeared. He felt better after reintroduction of fluoxetine 40 mg/day. Diagnosis was non-specified depressive disorder, but this episode could be retrospectively seen as delirium.

After being hospitalized on these four occasions in one year in our psychiatric department, the diagnosis of his systemic disease was revised by rheumatologists. The patient was diagnosed as suffering from systemic lupus erythematosus associated with secondary Sjögren's syndrome. From September 1997, he received cyclophosphamide 2 g intraveinously per month during 6 months. His vision improved dramatically. His ocular dryness became milder. His mood is now stable. He has not suffered from hallucinations or delusion since.

Psychiatric disorders in SLE--During the course of SLE, the occurrence of psychiatric manifestations varies widely from 5 to 83%. They include psychotic disorders, major depressive disorders, subtle cognitive disorders and personality disorders of histrionic type. Etiopathogenic hypothesis are: direct activity of the disease on the central nervous system by autoantibodies (antiphospholipide and antiribosome P autoantibodies) (18, 19) or cytokines (interleukin 2, interleukin 6, alpha interferon) (38, 59), side-effects of glucocorticosteroids and hydroxychloroquine (16) or anxious reaction to a chronic and potentially lethal illness (43, 54).

Nevertheless, immunologic and cerebral imagery research suggests that psychiatric disorders are related to vasculitis and non-inflammatory vasculopathy of the small cerebral blood vessels. The management of the patients should include treatment of the disease itself and specific psychotropic treatment. Glucocorticosteroids and especially intravenous infusions of immunosuppressive agents, such as cyclophosphamide, are effective. Psychotropic drugs must be used, making sure to avoid SLE-inducing drugs, like chlorpromazine, carbamazepine and lithium carbonate (19, 20, 45). In addition, psychologic care is essential.

Psychiatric disorders in SS--During the course of the primary SS, the occurrence of psychiatric disorders is large as well: from 20 to 70% (47, 61, 62). They are mainly major depressive disorders, anxiety disorders, cognitive disorders and dementia. Brief psychotic disorders and delirium are rare. Etiopathogenic hypotheses are similar as those in SLE, with some differences: antiphospholipide and antiribosome P autoantibodies are not usually found in SS and anti-Ro (SSA) autoantibodies in serum are associated with psychiatric disorders (3-11, 61).

According to Drosos et al. (29, 30), psychiatric disorders are explained by psychological distress. This slowly progressive fluctuating disease creates constant discomfort from dysphagia, dyspareunia and functional disability. Some of these manifestations can be treated by corticosteroids and psychotropic drugs. Drugs with anticholinergic side-effects, like phenothiazines, tricyclic antidepressants and hydroxyzine which can enhance the oral dryness have to be avoided. Social and psychological support is important too.

DISCUSSION: The diversity of psychiatric morbidity in SLE and SS may be due to differences in patient selection and a lack of uniform clinical criteria. Studies which use standardized diagnostic criteria and control groups don't allow one to come to a conclusion about the relative prevalence of the psychiatric disorders in these autoimmune diseases. This will probably be resolved thanks to the recently published "American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes" (1).

Finally, we can ask ourselves if there is a significant number of undiagnosed SLE and SS in psychiatric departments. Two studies report systematic search for SLE in psychiatric patients. In 1992, Hopkinson et al. (39) searched for several autoantibodies in serum samples of nearly 300 hospitalized psychiatric patients. In 1993, Van Dam et al. (65) did the same with more than 2,000 patients admitted to a psychiatric hospital. Hopkinson et al. found 1% undiagnosed SLE, which is much higher than in general population, and recommended to search SLE in every patient with a high erythrocyte sedimentation rate in psychiatric services.

Results of the Van Dam et al. study suggest on the contrary, that SLE is not a common cause of admission to psychiatric hospitals. There is no study which report systematic search of Sjögren's syndrome in a psychiatric department. This is probably because most of patients receive or have recently received psychotropics with anticholinergic side-effects which is an exclusion criteria of SS.

CONCLUSION: Psychiatrists should keep in mind that SLE and primary SS are potential causes of psychiatric manifestations when examining patients with multiple unexplained somatic complaints and psychiatric symptoms. They should then search for autoantibodies in the serum after careful physical examination. Diagnosis of SLE or SS could lead to a better adapted prescription of corticosteroids and/or immunosuppressive drugs and specific psychotropic drugs, making sure to avoid lupus-inducing drugs in SLE and drugs with anticholinergic effects in SS. The existence of psychiatric manifestations in SLE and SS constitutes an indisputable clinical reality that each practitioner must be able to recognize and treat.
 

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Interesting case study Pollianna.

A shame though that the penny didn't drop after this:

The lumbar punction revealed blood cells. Cerebral computer tomography showed subarachnoid hemorrhage. The diagnosis was meningeal hemorrhage due to vasculitis.
:rolleyes::rolleyes:

With a subarachnoid hemorrhage and evidence of vasculitis then most docs with half a brain would realise there was systemic process going on and run more tests and have put him on immune suppressants at that point :rolleyes: rather than just the pred which helped as they say and then just let him go!

Sometimes I wonder...............

love
Lily
 

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The Other Illinois Tammy
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Pollianna,
This is interesting because I have noticed that many of the people I talk to in here are on anti-depressants. I know that it is not the same thing but still interesting facts. Did wish it was in plainer terms but still managed to understand the information. Thank you very much.
Tammy
 

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Thank You.

This was especially interesting to me. I suffered repeated mental hospitalisations, over the course of 10 years..having c.n.s. lupus. I finally, worsened to the point of pychosis.

I had the very same symptoms and finally the diagnosis. I know, I started on the Cellcept just in the knick of time..I could tell, I was dying. My husband came home and found me sheet white. I was stumbling around, and slurring my incoherent speech. Not enough blood to my brain.

I am going to print this article off..and take it to my phychiatrist on monday. (As if he doesn't have enough to read). :lol:

Thanks again..
Sandy
 

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Thank you for sharing this. I have also had cns/depression episodes for decades. I have had psych help which has helped me to stay the course. Interesting that they found SS more readily than they found SLE.

The former TALS, The American Lupus Society, was founded because the daughter of the founders was dx as a schizophrenic, treated in mental health facilities for years, and when she died, it was determined on autopsy that she had SLE all along, not schizophrenia.
Sally
 

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Certainly food for thought here. I recall Dr Hughes' comments several years ago that a good proportion of those hospitalised for psychiatric illness very possibly have lupus or similar. I have the impression they are at last starting to gain better understandings of how the mind is affected - blood/ brain barrier being crossed and all that sort of thing. I know that when I first started reading about lupus 12+ years ago there used to be hardly any mention of depression other sorts of mental illness and psychosis being caused by lupus.
It is of course a very sensitive, fraught topic !

Pollianna, do you by any chance have a date for this article?

All the best
Clare
 

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Thank you for an interesting post. I had a horrid experience shortly after lupus diagnosis when I had mental health problems and did not realize that they were part of having a lupus flare up.

In my case I had hypomanic symptoms (sometimes called affective disorder,) with symptoms similar to the "high" that people with bi-polar disorder get.
I was not sleeping, was going on spending sprees, and had uninhibited and bizarre behaviour, as well as confusion, memory loss, and a dry mouth.

Unfortunately I did not know that Lupus could cause mental as well as physical problems, and I did not have the insight to realize how ill I was becoming. Hence I worried all family and friends around me, and eventually I needed a stay on a psychiatric ward and medication to sort things out.

Since then my mental health has been relatively stable. I have the support of a mental health team, medication for when I'm actually experiencing severe symptoms (I don't usually need medication unless thing get really bad), and I've been much healthier.

In my experience recognising the signs and symptoms of my mental health problems and knowing that these can be part of having lupus (In my case usually as part of having a lupus flare) has helped me to manage and control my illness

Please do not be afraid to ask for help if you need it. Getting mental health help without feeling stigmatized by that, has really helped me (You would report and treat physical symptoms of Lupus so don't be frightened to report and treat mental health symptoms)
 

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Thank you so much for your post.I am currently going through this at the moment exactly what you are describing! I honestly have found it a frightening experience.My doctor is going to be in touch with a therapist I never knew it was part of having lupus.
 

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Pollianna
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Sorry Clair, no date :( Part of my process is short term memory problems

I am glad that this post was of use to a few people as it was me. I am amazed at how intelligent and lucid we all seem to be whilst displaying what the Docs call Phsychiatric symptoms.

I too have found that I suffered from/suffer from mental health issues when in flare ( anxiety/panic attacs/intrusive thoughts) also terrible pms symptoms which I always felt were of a biological origin. I had agoraphobia ( after giving birth) and have suffered panic attacks since the age of 18. At my worst it was always emotional fragility coupled with physical illness. Of course doctors prescribed anti depressants which had the effect of making me present almost as bipolar in my mind. I know that I am not mentally ill and do feel that I have a disorder of the CNS. I felt this long before I suspected Lupus.....Just shows how intuitive we are

Wheelie, I understand exactly what your saying and thank you. I don't wish to be at all unconventional. I have a longstanding dislike of SSRI's and anti depressants in general. I remember telling my GP that me taking anti depressants felt akin to putting a plaster over a bullit wound. I knew there was something underneath that needed to be addressed. I always found if I had physical help and could rest my emotional problems subsided far quicker than they did with medication but everyone is different and I am glad to know that they help you. I am a great believer in CBT....
 

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:foryou: thanks for the post!

As evidenced by the responses even here, there are very few who are aware of the nueropsychiatric and mental health aspects of this disease.
 

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Hi Guys

This was very interesting. Thanks for posting. I had the impression (someone correct me if I am wrong) that the medical profession are realizing that there is a lot more CNS involvement much earlier in SLE than previously thought. Depression is maybe one of the first signs. I suppose it could also be a natural effect of dealing with a chronic illness. I personally have felt much more emotionally stable since my rheumy put me on Cymbalta. she said that my wierd mood swings(usually bursting into tears for no reason in supermarkets and such, very embarrassing! Also just feeling like I couldn't cope with silly little things) were definitely related to CNS involvement of SLE. Anybody else had their rheumy make that connection?

Rose
 
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