Psychiatric Symptoms as the Initial Presentation of Multiple Sclerosis—Report of a Rare Case

Dear Sir,

Multiple Sclerosis (MS) is a chronic inflammatory, demyelinating disease of the central nervous system. It usually presents with limb weakness, visual disturbances, ataxia, bladder and bowel dysfunctions, and sensory deficits. ¹ Only rarely have psychiatric symptoms been reported as an initial manifestation of MS. ² Here, we report an 18-year-old girl who presented with behavioral changes suggestive of possible emotionally unstable personality traits associated with mixed affective state 18 months prior to the development of neurological symptoms of MS.

Case Description

Miss X, a temperamentally easy child, presented with gradual onset of behavioral changes of six months duration. She had a decline in academic performance, excessive and inappropriate interactions with boys, irritability, and two deliberate self-harm (DSH) attempts. Her parents were separated for the past five years, and she was staying with her mother. There was no significant medical, psychiatric, or family history. She reported no first-rank symptoms, deterioration in personal hygiene or biological functions, or other neurological or systemic symptoms.

On examination, she was argumentative, irritable, and less concerned about the DSH attempt and the consultation. No obvious cognitive or neurological deficits were noted. Differential diagnoses of Emotionally Unstable Personality Disorder and mixed affective episode were considered and treatment plans were discussed. However, she was lost to follow-up, and no treatment was received.

Excessive and inappropriate interactions with boys and irritability subsequently persisted. The mother had to relocate near their college as the management was reluctant to accommodate her in the hostel. After one year of the psychiatric consultation, she developed acute onset right-sided weakness and episodes of transient blurring of vision. In addition, there was a weakness of the right upper and lower limbs (Medical research council grade 3) with positive Lhermitte’s sign. Mental status examination revealed increased talk, euphoric mood, and intact cognitive functions.

MRI brain (T2 and FLAIR [fluid attenuated inversion recovery]) revealed ovoid hyper intense lesions in the periventricular and subcortical white matter, perpendicular to the body of lateral ventricles (Dawson’s fingers, Figure 1), and irregularity of ependymal stripe on the undersurface of the corpus callosum. Serum testing for antinuclear antibodies, antibodies against double-stranded DNA, lupus anticoagulant, vitamin B12 levels, and thyroid antibodies, among other tests, were negative.

Figure 1.

Cranial MRI Showing Sagittal T2-Weighted FLAIR Views of the Demyelinating Lesions in the Juxtacortical Regions

CSF study revealed oligoclonal bands with elevated IgG index. Probable MS was diagnosed based on the revised McDonald criteria. ³ Inj. Methylprednisolone 1 gm daily was given for five days, followed by glatiramer acetate 20 mg per day, sodium valproate 1000 mg in divided dose, and psychotherapy sessions. Her neurological and psychiatric symptoms improved remarkably following the treatment of MS and the treatment with a mood stabilizer, and she is currently on regular follow-up.

Discussion

This case report emphasizes that though rare, mixed affective symptoms and possible emotionally unstable personality traits can be the initial manifestation of MS. The psychiatric aspects of the MS have gained attention since the last century, wherein intellectual and emotional disorders were noted to be frequent accompaniments during the course of the illness, with psychotic disorders observed infrequently. ²

In this case illustration, mixed affective symptoms, possible emotionally unstable personality traits, and academic decline were the initial manifestations, and more typical features of MS developed much later only. The psychiatric manifestations of MS can be grouped into mood and cognitive disorders. Depression, bipolar disease, and pseudobulbar affect are the common mood disorders, and irritability, apathy, disinhibition, and euphoria are the other symptoms. The etiology of psychiatric manifestations is not fully understood. ⁴ The evidences suggest that psychiatric symptoms in MS are usually associated with higher lesion load, specifically in the temporal periventricular area, and also with the presence of cortical lesions. Thus, damage to the white matter, leading to disconnection of the cortical areas and the basal ganglia, could be the underlying basis of the psychiatric symptoms. ⁵ This patient had multiple periventricular and subcortical lesions, including in the frontal and temporal regions. The orbitofrontal cortex is considered to be responsible for socially appropriate behavior and empathy, that is, impulsivity, liability, and personality changes. Disruption of the anterior cingulate cortex-orbitofrontal brain circuitry is thought to explain the above symptoms in this patient. ⁶

Cognitive deficits, common in MS, often manifested early and occasionally before the onset of physical symptoms. Information processing, working memory and attention are affected commonly. ⁷ Cognitive deficits may not be clinically observable early in the course, and the “functional reorganization” could explain this. This is the brain’s compensatory mechanism wherein the brain’s connectivity is altered to limit the expression of pathology. This would partly explain the disparity between the observed lesions and the intact cognitive functions in our patient. ⁸

Conclusion

Our case illustrates that although rare, mixed affective symptoms and possible emotionally unstable personality traits can be a forerunner of other MS symptoms. Hence, MS should be considered in the differential diagnosis of young patients with mood symptoms and abnormal personality traits.