Psychiatric Symptoms in Pediatric Multiple Sclerosis: A Case Series

Background: The prevalence of mood-related disorders has been estimated to occur in over 50% of adults with multiple sclerosis (MS).  The most common psychiatric disorders described in MS include depression and anxiety but an increased incidence of bipolar disorder and pseudobulbar affect have been well described in adults as well (Wilken and Sullivan, 2007); however, there is little literature describing psychiatric disorders and mood-related symptoms in pediatric MS (Weisbrot et al, 2010).  Less commonly, there have been reports of psychosis including hallucinations, delusions, paranoia and schizophreniform symptoms described in adult MS patients (Kosmidis et al, 2010).

Objectives: To evaluate the prevalence of mood-related issues in pediatric MS and clinically isolated syndrome (CIS).

Methods:  We evaluated behavior and mood-related symptoms in 26 pediatric patients, ages 7 to 18 years (mean=15), with a diagnosis of MS or CIS (who went on to be diagnosed with MS) utilizing the BASC-2, Parent Form.  All patients who were seen at Children’s Medical Center Pediatric Demyelinating Disease Clinic in Dallas, Texas between 2009 and 2012 were evaluated for clinical purposes.  We also performed a retrospective chart review to assess rates of referral to psychology/psychiatric services, and suicidality.  Furthermore, we completed a review of three patients exhibiting profound psychiatric symptoms in the context of MS.

Results: Approximately 27% of patients were exhibiting subclinical or clinically elevated symptoms of anxiety while approximately 36% were exhibiting subclinical or clinically elevated symptoms of depression.  Also, 26% of patients exhibited active suicidal ideations.  A total of 54% were referred to mental health professionals with 23% referred specifically for inpatient psychiatric evaluation.    

We will highlight three specific cases of pediatric patients with a diagnosis of relapsing remitting MS who exhibited rather profound psychiatric symptoms including one individual with acute psychosis and two individuals with a diagnosis of bipolar disorder, all of which required inpatient psychiatric admission for suicidal ideations during the course of their care.  In all of these cases psychiatric symptoms predated the diagnosis of MS. 

Conclusions:  Despite this small population of pediatric MS/CIS patients, the rates of mood-related issues are similar to those found in adult MS populations.  Further inquiry should be made into possible connections between the organic disease process of MS and psychiatric symptoms.  Clinicians should also keep in mind the developmental stage of adolescence and its role in the adjustment to and management of a chronic illness which might exacerbate psychiatric issues.  Lastly, psychological symptoms are often overlooked in the care of pediatric patient’s MS, and formal psychological evaluation can be valuable to this vulnerable population.