Psychiatric Problems in Lupus

The range of potential psychological and psychiatric problems affecting lupus patients is large. Difficulties may arise from the disease process itself, which commonly affects the brain, or from the general effects of having a chronic debilitating illness with a variable course - symptoms of fatigue, pain and muscle ache may contribute to disorder, which is a common depression in hospital and general practice patients. The idea of having a psychiatric disorder may be stigmatising, especially if patients or the involved doctors and nurses believe the symptoms are just a part of the illness, or 'all in the mind'. Rates of psychiatric disorder, depression and anxiety especially, are highest in the same demographic group as lupus patients, namely younger women. It can be difficult for people to explain complex problems in a busy outpatient clinic, so it pays dividends to give attention to the patient's emotional as well as physical health. It can be difficult to decide if symptoms such as fatigue and lack of energy are due to physical or mental causes and such a distinction may be unhelpful as physical and mental symptoms frequently co-exist and exacerbate each other. One solution is to investigate and treat the potentially treatable causes and then deal with other symptoms using a practical and problem-focussed approach.

It is clear that lupus directly affects the brain ('Neuropsychiatric lupus') in a third to two-thirds of patients (depending on diagnostic criteria used). These effects may be difficult to quantify, varying by day or by week and making assessment difficult. The pathological process underlying the disorder may depend on immune-complex deposition in the brain, vasculitis or stroke. At its most severe, lupus may cause seizures, strokes, memory loss and psychosis. Pathological causes of these neurological and psychiatric effects are varied and need proper investigation, especially as the response to typical psychiatric drugs such as neuroleptics (also called anti-psychotics or major tranquillisers) or mood stabilisers (lithium or certain drugs also used for epilepsy such as carbamazepine) may be limited, and a better response may obtain with treatment of the underlying disease process. Steroids themselves may cause depression, confusional states or euphoria and minor symptoms such as poor concentration, headache and mood swings also occur.

To further complicate the picture, neuropsychiatric symptoms are commonly found even when the biochemical markers of the disease such as ESR are normal. A history of brief confusional states ('delirium') or psychosis, with clouding of consciousness, agitation, fear, visual or auditory hallucinations or paranoid ideas (such as that people are persecuting the sufferer) is relatively common. These states are fortunately brief and last only hours or days before subsiding. Occasionally lupus causes an illness which is closer to schizophrenia or bipolar affective disorder (manic-depression). A very small minority of patients go on to develop a dementia syndrome, with loss of recent memory, personality change, speech and co-ordination problems.

The treatment of the psychiatric aspects of lupus clearly depends on the severity of the illness and whether the causes are directly or indirectly attributable to lupus itself or due to co-existent psychiatric problems. Some conditions are brief and self-limiting, requiring only reassurance and brief support. Where there are longer-term emotional problems or recurrent problems that are severe and distressing, referral to a psychiatrist is appropriate. When assessing patients who are very distressed it is appropriate to enquire sensitively whether they have felt that life was not worth living or had any suicidal ideas. Counselling or psychotherapies such as cognitive-behaviour therapy or more analytical therapies may be very helpful. Cognitive-behaviour therapy (CBT) has the advantages of being brief and problem-focussed, usually lasting between eight and twenty weeks, and it has proven to be effective in people whose fatigue is not obviously physical in origin.

For more neuropsychiatric presentations of the illness, the psychiatrist or psychologist may be able to help by assessing cognitive impairment or memory problems. These may require more lengthy psychometric testing, which may be able to pinpoint functional difficulties such as visuo-spatial problems or language problems. Imaging investigations such as magnetic resonance (NM) and CT scanning are also extremely helpful, as are EEG recordings. In the future, scans, which are able to look at the function as well as the structure of the brain, such as positron emission (PET) scans, may become increasingly useful.