Course Title: CE 5. The Neuropsychiatry of Multiple Sclerosis

Credit Hours: 3.0

Instructor(s) Anthony Feinstein, MPhil, PhD, FRCP

The Neuropsychiatry of Multiple Sclerosis

Abstract & Learning Objectives

Neuropsychiatric difficulties in multiple sclerosis may be divided into two broad categories, namely disorders of mood and affect on the one hand and cognitive dysfunction, on the other. The first category is dominated by depression which may affect up to 50% of MS patients over the course of their lifetime. Recent MRI data suggest a link between depression and atrophy and lesions affecting medial frontal and temporal brain regions. MRI findings can, however, account for little more than 40% of the depression variance suggesting a prominent role for psychosocial factors in the pathogenesis of depression. Depression exerts negative effects on quality of life and cognition and is also associated with an increased suicide rate in MS patients. For that reason, not missing the diagnosis and providing effective treatment are essential. A Cochrane Review suggests that cognitive behavior therapy is the treatment of choice. Pseudobulbar affect may affect up to 10% of MS patients. MRI data can account for 75-80% of the PBA variance. The syndrome responds well to a number of medications, including the tricyclic and SSRI antidepressants. Bipolar Affective Disorder is twice as common in MS patients as the general population. Euphoria is present in 9-13% of MS subjects. There are no treatment trials for either of these two syndromes. Impaired cognition is present in 40-70% of MS patients, depending on disease course. The hallmark deficits are slowed information processing speed, impaired memory and executive dysfunction. Structural and functional brain MRI studies have revealed a robust correlation between cognitive deficits and the imaging data. Cognitive reserve, as in other neuropsychiatric disorders and the aging literature, is considered protective. Pharmacotherapy is not effective in treating cognitive dysfunction, but cognitive rehabilitation is going through a renaissance and may offer enduring benefits to a subgroup of patients. Preliminary evidence suggests that smoking cannabis, which might relieve pain and spasticity in some MS patients, may be associated with a further deterioration in cognitive function.

Anthony Feinstein, MPhil, PhD, FRCPC

Anthony Feinstein, MPhil, PhD, FRCPC

Professor, Department of Psychiatry
University of Toronto

At the completion of this workshop, participants will be able to:
1. List the common behavioral disorders associated with MS.
2. Describe the characteristic clinical features of the disorders of mood and affect in the context of MS.
3. Provide an approach to treating disorders of mood and affect in MS.
4. Choose the most sensitive cognitive tests to include in a neuropsychological battery for MS.
5. Formulate a treatment plan for people with MS who are cognitively impaired.
6. Explain how the results of neuroimaging can influence clinical practice in MS.

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Speaker Biography

Dr. Feinstein received his medical degree in South Africa at the University of the Witwatersrand. Thereafter he completed his training in Psychiatry at the Royal Free Hospital in London, England, before training as a neuropsychiatrist at the Institute of Neurology, Queen Square in London. His Master of Philosophy and Ph.D. Degree were obtained through the University of London, England. He is currently a Professor of Psychiatry at the University of Toronto.

His neuropsychiatry research focuses on the search for cerebral correlates of behavioral disorders associated with multiple sclerosis, traumatic brain injury, and hysteria (Conversion Disorders). He is currently Chair of the Medical Advisory Committee of the MS Society of Canada.

Dr. Feinstein is also involved in a series of studies of relevance to current issues within our society. The questions being addressed are: How are journalists affected emotionally by their work in zones of conflict and what motivates them to pursue such dangerous occupations?

In 2000-2001 he was awarded a Guggenheim Fellowship to study mental health issues in post-apartheid Namibia. This led to the development of that country’s first rating scale for mental illness. Subsequent work in Botswana produced that country’s first rating scale for mental illness as well.

Dr. Feinstein is the author of Dangerous Lives: War and the Men and Women Who Report It (Thomas Allen, Toronto 2003), In Conflict (New Namibia Books, 1998), The Clinical Neuropsychiatry of Multiple Sclerosis (Cambridge University Press 1999, with a second edition in 2007), Michael Rabin, America’s Virtuoso Violinist (Amadeus Press, 2005, with a second edition in 2011) and Journalists Under Fire: the Psychological Hazards of Covering War (John Hopkins University Press). His most recent book is Battle Scarred (Tafelberg Press, 2011). He has published widely in peer-reviewed journals and has authored many book chapters.

In 2012, a documentary, “Under Fire” produced by Dr. Feinstein and based on his research of journalists in war zones was shortlisted for an Academy Award. The documentary received a 2012 Peabody Award.