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Psychiatric Aspects of Lupus: Mood & Cognitive Function Nicholas A. Doninger, PH.D. Assistant Professor, Psychiatry Wright State University Clinical Neuropsychologist Kettering Medical Center, and is now in Ohio (he trained at U. of Chicago and worked on a variety of SLE research projects with me as part of his neuropsychology research training) Tammy O. Utset, M.D., M.P.H. Associate Professor of Medicine, University of Chicago JOSEPH W. FINK, PH.D. Assistant Professor of Clinical Psychiatry, University of Chicago INDIVIDUALS WITH LUPUS can develop a variety of psychiatric problems, which can aggravate other symptoms. Although these problems generally do not differ in nature from individuals with other types of chronic diseases, it remains unclear whether psychiatric symptoms reflect the effects of disease activity on the brain (e.g., immunological response), misattributions or a stressful reaction to physical disabilities and psychosocial dysfunction. The most common psychiatric problems experienced by individuals with lupus include depression, anxiety and, rarely, psychosis Clinical depression is a disabling, unpleasant and prolonged mood associated with a variety of symptoms: sadness, sleep and appetite changes, irritability, guilty feelings, lowered self-esteem, inability to concentrate, lack of interest in enjoyable activities, and suicidal thoughts. Physical features may include headaches, body aches and pains, constipation or diarrhea, and fatigue. People who suffer with clinical depression do not necessarily experience all of these symptoms. Anxiety disorders develop when worry and fear become persistent and overwhelming and start to interfere with daily life. An often-overlooked symptom in SLE is anxiety attacks Ñ or, "panic attacks," which are a sudden, unrealistic sense of impending doom, which occurs for no apparent reason. Lupus psychosis refers to a severe mental disturbance marked by difficulty judging reality, organizing thoughts, and/or hallucinations (sounds or sights). It is believed to be due to the direct effects of lupus on the brain. Although the symptoms may resemble schizophrenia, in lupus they generally are not chronic in nature (i.e., the symptoms go away over time with treatment for active lupus). Fortunately this type of psychiatric problem is the least commonly observed in lupus patients. Physicians are becoming increasingly aware of these problems and are making these diagnoses with more frequency. If you are having significant problems like these, it is very important that you review them with your rheumatologist, as treatment for lupus and psychological symptoms differ greatly. Often a psychiatric consultation may be helpful in clarifying the diagnosis and starting appropriate treatment(s). HOW COMMON ARE PSYCHIATRIC PROBLEMS IN LUPUS? THE FREQUENCY OF PSYCHIATRIC SYMPTOMS is estimated to be as high as 60%. Psychiatric symptoms typically occur early in the illness and may predate the diagnosis by as much as a year. Although infrequent, psychosis is now used by doctors as a hallmark criterion for the diagnosis of systemic lupus. Depression and anxiety often go unrecognized among those with medical illnesses because symptoms such as lethargy, loss of interest, and insomnia resemble those associated with the underlying medical condition. The common notion that those with a chronic illness should feel depressed "because they are sick" may needlessly contribute to the under-treatment of patients who respond well to standard treatments. WHAT CAUSES PSYCHIATRIC PROBLEMS IN LUPUS? THE CAUSES OF CLINICAL DEPRESSION IN LUPUS remain a topic of controversy. Individuals with lupus can become depressed as a result of making continuous life adjustments and the negative impact of the disease on self-image and functional capacity. Alternatively, the disease can cause symptoms of depression through the effect of autoimmune processes on the brain and other organ systems such as the heart and kidneys. Medications used to treat lupus such as steroids, may also induce mood changes. Panic attacks are thought to be due to over activity of the brain's sympathetic nervous system releasing large amounts of adrenalin, which causes a racing heart, rapid breathing, sweating, and trembling. Most psychotic episodes occur when lupus targets the brain, e.g., vasculitis (inflammation of blood vessels). Although uncommon, psychosis may emerge as a toxic side effect of steroid medications such as prednisone. Other rare causes of psychosis include hyponatremia (or low blood levels of sodium), seizures, hyperventilation, or antimalarial therapy. WHAT IS THE TREATMENT AND PROGNOSIS FOR PSYCHIATRIC PROBLEMS IN LUPUS? DEPRESSION: Treating and managing depression in lupus requires a comprehensive approach. Any underlying medical factors contributing to the depression must be identified and addressed. Antidepressant medications are often used and can be very helpful in improving the patient's outlook and level of function. Selective Serotonin Re-uptake Inhibitors (SSRIs) have more favorable side effect profiles and work more quickly than the older tricyclic antidepressants; however, tricyclics may still be used when sleep disturbance is a prominent feature. For those who are unable to tolerate SSRIs, venlafaxine and Moclobemide may be suitable. Psychotherapy can also be helpful in assisting people to understand relationships between their feelings and illness, and coping more effectively with daily stress and life adjustments. Effective treatment also involves the cooperation of the patient, and the support, education, and involvement of the patient's family and close friends. Unfortunately, depression can recur Ñ so it is important to recognize the signs and symptoms so that treatment can be started as quickly as possible. ANXIETY: Laboratory tests and a physical examination may be useful in detecting medical conditions, which could be contributing to anxiety. Treatments used in anxiety disorders include cognitive behavioral therapy (CBT), exposure, anxiety management, relaxation techniques, and lifestyle changes. In CBT, individuals learn to cope with situations or physical sensations that cause distress through gradual and controlled exposure to them. In addition, unproductive or harmful thoughts, which may contribute to anxious feelings are targeted. The individual critically examines the logic underlying their feelings and learns to develop more adaptive ways to appraise the source of their distress. Relaxation techniques, including breathing re-training and meditation may also be added to help develop skills in coping more effectively with the physical symptoms of anxiety. Drugs used to treat anxiety disorders include the SSRIs and Tricyclics, benzodiazepines, beta-blockers, and monoamine oxidase inhibitors. Each of these treatments is effective and may be offered alone or in combination. Changes in lifestyle, including exercise and diet, can also help improve the symptoms of anxiety. In particular, a program of regular exercise can: 1) reduce muscle tension, 2) lower the level of adrenalin (the substance responsible for feelings of arousal), and 3) discharge pent-up frustrations, which can aggravate panic reactions. Dietary modifications can also have a direct impact on the body's internal physiology. In particular, the elimination of caffeine and nicotine may be critical for reducing anxiety and panic attacks. LUPUS PSYCHOSIS: The symptoms of psychosis are typically treated with antipsychotic medications, high doses of cortisone-related (steroid) medications, such as prednisone or prednisolone, and sometimes powerful immune suppression drugs, such as cyclophosphamide (Cytoxan). NEUROCOGNITIVE DISTURBANCES WITH LUPUS NEUROCOGNITIVE DYSFUNCTION is also a common and overlooked clinical feature of lupus estimated to occur in up to 80% of affected individuals. The diversity of cognitive impairments parallels the considerable variability of the disease process. Deficits in learning and/or memory, reasoning, verbal fluency, motor function, basic attention, and information processing speed are the most consistently described. These deficits have been characterized as generally mild to moderate in severity, fluctuating over time, and non-progressive in nature; however, recent research has associated a higher risk for progression of cognitive impairments with the presence of certain disease activity markers, including antiphospholipid antibodies, matrix metalloproteinases and proinflammatory cytokines. While antiphospholipid antibodies can be checked by your doctors (positive in around 40-50% of SLE patients), the other factors are measured purely as a research tool at this point. In general, objective tests of cognitive performance are unrelated to perceived stress, depression, and anxiety, suggesting that cognitive impairment may be a primary disease manifestation consistent with other immunemediated disease with neurologic involvement (e.g., acquired immune deficiency syndrome and multiple sclerosis). Alternatively, the relationship between depression and cognitive performance may be determined by more subtle aspects of lupus, including sleep disturbance, fatigue, and pain as has been suggested in studies of individuals with multiple sclerosis. Neuropsychological assessment with a qualified neuropsychologist is useful in delineating cognitive strengths and weakness, including the extent to clinical factors such as depression may be moderating cognitive performance, which can ultimately contribute to effective treatment planning. Currently, there is no specific therapy which improves chronic neurocognitive impairment from lupus, and interventions focus on adaptive strategies to compensate for areas of cognitive weakness. If impairments are due to depression, treating the depression can improve brain function. Lupus neurocognitive impairment is an area of intense research which may yield therapeutic interventions in the future. Thus, it is reasonable to identify the problem and track it over time if you have substantial difficulties with memory, concentration or other mental function. Again, this should be discussed with your treating rheumatologist, who should be made aware if you are having these symptoms and can assist you in deciding if formal evaluation would be helpful.  |
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