Multiple sclerosis (MS) is a disease of the brain and the mind. Emotional changes, abnormalities of affective expression and cognitive decline have been recognised since the turn of the century but, with a few exceptions”2 have been overlooked, until new imaging techniques made it possible to study brain pathology in vivo.
We have learned much about the psychiatric features and patterns of cognitive impairment and the frequency with which they occur, but the link with brain pathology has proved more elusive. The multifaceted interactions between environmental and organic factors in the causation of psychiatric and cognitive abnormalities and the fluctuations in lesion size and number, often without overt clinical manifestations, need to be better understood before the psychopathology of MS can be fully explained. Psychiatric abnormalities Transient mood changes, irritability and anxiety are the rule rather than the exception in MS. Two thirds of patients experience these symptoms in the course of a year and in a third they will be severe enough to merit the diagnosis of major depression.3 A life time prevalence for this diagnosis ranges from 40-50%4 while an increased association with bipolar affective disorder has also been found.56 Fatigue, common to both MS and depression, cannot account for this increased morbidity.
Transient hypomanic episodes may occur in association with steroid teatment and affective symptoms in general are more common during exacerbations and in patients with a chronic progressive course,9 but they are not closely related to the degree of physical disability.’01’ The vulnerability of MS patients to psychiatric illness is comparable to that of patients with temporal lobe epilepsy’2 and much higher than in the general population3 or similarly disabled patients without brain disease.” These facts, added to the observation that the family history and incidence of psychiatric illness before the onset of neurological symptoms are similar to those in the general population,’3 argue in favour of a causal role for brain pathology. This is, however, only half of the story as psychiatric morbidity and severity of MRI abnormalities are not highly correlated, whilst the degree of stress perceived by the patient is a much better predictor of an abnormal mental state.” This suggests an interactional -model in which the vulnerability created by the presence of brain damage greatly enhances the effect of environmental factors in producing psychiatric disease.
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