Psychosis: Is it a medical problem?
Ms. B hears voices and is paranoid but has no other symptoms of a psychotic disorder. The challenge: narrow the differential diagnosis and determine what’s causing her hallucinations.
Diagnosis of MSrelated psychosis has been addressed only in case reports or small studies, most of which have not clearly defined psychosis or adequately described the symptoms or confounding factors such as medications. Findings on prevalence of psychosis as the initial presentation in MS are more limited and confounded by instances in which neurologic symptoms might have been overlooked.9,11
Few studies have investigated whether lesion location correlates with specific neuropsychiatric symptoms. In one study,8 brain MRI taken within 9 months of presenting symptoms showed that MS was not significantly more severe among patients with psychosis compared with nonpsychotic MS patients. These data support psychosis as a possible early finding in MS.
At least two studies12,13 suggest a correlation between temporal lobe lesions and psychosis, but both study samples were small (8 and 10 patients) and used a combination of diagnoses. One case report also supports this correlation.14
Table 2
Medical conditions that can cause psychotic symptoms
| Cerebral malignancy (primary and metastases) | |
| Cerebral trauma | |
| Cerebral vascular accident | |
| Creutzfeldt-Jakob disease | |
| Delirium | |
| Dementia | |
| Epilepsy | |
| Huntington's disease | |
| Infection | |
| Multiple sclerosis | |
| Parkinson's disease | |
| Systemic lupus erythematosus | |
| Source: Reference 4 | |
Treating ms-related psychosis
MS-related psychosis should abate with MS treatment, but no systematized studies have verified this or determined which antipsychotics would be suitable. Single case reports suggest successful treatment with risperidone,13 haloperidol,15 clozapine,16 or ziprasidone.17 Ms. B showed initial improvement with risperidone, but because she was lost to follow-up we cannot say if this medication would work long-term.
Related resources
- Feinstein A. The clinical neuropsychiatry of multiple sclerosis. New York: Cambridge University Press; 1999.
- National Multiple Sclerosis Society. www.nationalmssociety.org.
Drug brand name
- Clozapine • Clozaril
- Risperidone • Risperdal
- Haloperidol • Haldol
- Ziprasidone • Geodon
- Lorazepam • Ativan
Disclosures
Dr. Higgins reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Rafeyan is a speaker for AstraZeneca, BristolMyers Squibb Co., Eli Lilly and Co., GlaxoSmithKline, Pfizer, and Wyeth. He is also an advisor to Abbott Laboratories and Forest Pharmaceuticals.
