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Child Psychiatrist /Adult Psychiatrist

Neuropsychiatric Symptoms an Important, Overlooked Feature of Lupus

Neuropsychiatric symptoms, including nightmares and hallucinatory "daymares," may be a more important aspect of systemic lupus erythematosus (SLE) than formerly recognized, according to a qualitative mixed methods study published in The Lancet Discovery Science's eClinicalMedicine. The findings suggested these neuropsychiatric symptoms can sometimes present as prodromal and other times act as an early warning system for a forthcoming flare.


Neuropsychiatric Symptoms

"For clinicians, the key point is to be aware that neurological and psychiatric symptoms are much more common in patients with lupus and other autoimmune systemic rheumatic diseases than previously thought," lead author Melanie Sloan, PhD, of the Department of Public Health and Primary Care at the University of Cambridge in Cambridge, England, told Medscape Medical News.


"If clinicians — and some do already — could all ask about and document these symptoms for each patient, the usual progression of symptoms in a flare can then be monitored, and patients could be supported and treated at an earlier stage," Sloan said. "Another key point is to consider systemic autoimmune diseases at an early stage if a patient presents with multiple seemingly unconnected symptoms, which often include both physical and mental health symptoms."


Alfred Kim, MD, PhD, an associate professor of medicine in rheumatology at Washington University School of Medicine in St. Louis, Missouri, noted the difficulty of determining what neuropsychiatric symptoms may be linked to lupus vs those occurring independently or as part of a different condition.


"There is some controversy about whether the neuropsychiatric manifestations that we have long attributed to lupus actually are due to lupus," Kim told Medscape Medical News. Kim was part of a group that published a review on potential mechanisms underlying neuropsychiatric symptoms described by a committee of the American College of Rheumatology.

Since that committee's findings, "we have long assumed that if we saw these symptoms, the best explanation was lupus," Kim said. "The problem is that, in the real world, we can see many of these manifestations in patients with lupus that do not get better with lupus meds. This opens up the very real possibility that another etiology is at play."


Kim noted that mood disorders such as depression and anxiety may be part of the neuropsychiatric SLE criteria, but they failed to correlate with overall lupus disease activity in a cohort he evaluated. That makes it hard to distinguish whether those neuropsychiatric symptoms can actually be attributed to lupus. "Probably the more accurate interpretation is that there may be certain symptoms, such as nightmares, that indicated a prodrome of lupus," he said. "Whether these are actually lupus symptoms is debatable to me."


There remains value in initiating discussions about these symptoms with patients, however, because the stigma associated with neuropsychiatric symptoms may prevent patients from bringing them up themselves.


"It is important to remember that many of these patients, in common with other chronic diseases, will often have had long and traumatic journeys to diagnosis," including having been misdiagnosed with a psychiatric condition, Sloan said. "Many of the patients then lose trust in doctors and are reluctant to report symptoms that may lead to another misdiagnosis."


Clinicians may also be reluctant to bring up these symptoms, but for different reasons. Their reluctance may stem from insufficient time to discuss the symptoms or not having the support available to help the patients with these particular problems, Sloan said. The invisible nature of these symptoms, which lack biomarkers, makes them harder to identify and makes listening to patients more important, she added.


Study Details


In planning for the study, the researchers first searched the existing literature for studies involving neuropsychiatric symptoms in patients with systemic autoimmune rheumatic diseases (SARDs). "The literature indicated frequent underreporting and misattributions of neuropsychiatric symptoms in SLE and other SARD patients, and clinician-patient discordance in neuropsychiatric symptom attribution," the authors reported.


During 2022-2023, the researchers conducted two surveys, one with 676 adult patients with SLE and one with 400 clinicians, recruited through social media, online patient support groups, and professional networks. All patients self-reported an SLE diagnosis that the researchers did not independently confirm. The patients were predominantly White (80%) and female (94%), ranging in age from 18 to over 70, with most falling between ages 40 and 69. Most patients lived in the United Kingdom (76%) or Europe (15%).


The clinicians included 51% rheumatologists, 24% psychiatrists, 13% neurologists, 5% rheumatology nurses, 3% primary care physicians, and 7% other clinicians. Nearly half of the clinicians (45%) were from the United Kingdom, with others from the United States or Canada (16%), Europe (17%), Asia (9%), Latin America (8%), Australia or New Zealand (3%), or elsewhere (3%).


The patient surveys asked whether they had experienced any of the 29 neuropsychiatric symptoms. For the symptoms that patients had experienced at least three times in their lives, the survey asked when they first experienced the symptom in relation to their SLE onset or other SLE symptoms: Over a year before, within a year of (on either side), 1-4 years after, or more than 5 years after onset/other symptoms. "Other quantitative data included timings of disrupted dreaming sleep in relation to hallucinations for those patients reporting experiencing these," the authors wrote.


The researchers also conducted videoconference interviews with 50 clinicians, including 20 rheumatologists, and 69 interviews with patients who had a systemic autoimmune rheumatic disease, including 27 patients with SLE. Other conditions among those interviewed included inflammatory arthritis, vasculitis, Sjögren disease, systemic sclerosis, myositis, undifferentiated and mixed connective tissue diseases, and polymyalgia rheumatica. During interviews, the term "daymare" was used to discuss possible hallucinations.


Linking Neuropsychiatric Symptoms and Disease


Four themes emerged from the analysis of the surveys and interviews. First, despite many rheumatologists stating that it was an "established theory" that most neuropsychiatric symptoms related to SLE would initially present around the time of diagnosis or disease onset, the findings from patients and interviews with psychiatrists did not align with this theory. The first presentation of each neuropsychiatric symptom only occurred around the onset of other SLE symptoms, about one fifth to one third of the time. In fact, more than half of the patients with SLE who had experienced hallucinations or delusions/paranoia said they occurred more than a year after they first experienced their other SLE symptoms.


Patient experiences differed in terms of whether they believed their neuropsychiatric symptoms were directly related to their SLE or other rheumatic disease. Some did attribute the symptoms, such as hypomania, to their rheumatic illness, while others, such as a patient with major depression, did not see the two as linked.


A second theme focused on pattern recognition of neuropsychiatric symptoms and the onset of a disease flare. "For example, several patients described how they felt that some types of depressive symptoms were directly attributable to active inflammation due to its time of onset and differences in type and intensity compared to their more 'reactive' low mood that could be more attributable to a consequence of psychological distress," the authors wrote. Another common report from patients was experiencing a sudden, intense fatigue that coincided with a flare and differed from other types of fatigue.


Some patients could recognize that a flare was coming because of familiar neuropsychiatric symptoms that acted like an "early warning system." Often, however, these symptoms "were absent from current diagnostic guidelines and only rarely identified by clinician interviewees as related to SLE/NPSLE," the authors found. "These neuropsychiatric prodromal symptoms were reported as sometimes preceding the more widely recognized SLE and other SARD symptoms such as joint pain, rashes, and other organ involvement." These symptoms included sudden changes in mood (usually a lowering but sometimes mania), increased nightmares, a "feeling of unreality," or increased sensory symptoms.


Other patients, on the other hand, had not considered a link between neuropsychiatric symptoms and their rheumatic disease until the interview, and many of the clinicians, aside from psychiatrists and nurses, said they had little time in clinic to gather information about symptom progression.


Nightmares and Daymares


A third theme centered on disrupted dreaming sleep, nightmares, and "daymares" as a prodromal symptom in particular. Some patients had already drawn a connection between an oncoming flare of their disease and these dreaming-related symptoms, while others had not considered a link until the interviews.


"Several SLE patients recounted flares consistently involving the segueing of increasingly vivid and distressing nightmares into distorted reality and daytime hallucinations," the authors reported. Flare-related nightmares in particular "often involved being attacked, trapped, crushed, or falling." Patients tended to be more forthcoming about hallucinatory experiences when the term "daymare" was used to describe them, and they often related to the idea of feeling "in-between asleep and awake."


Only one of the rheumatologists interviewed had considered nightmares as potentially related to SLE flares, and several appeared skeptical about a link but planned to ask their patients about it. Most of the specialists interviewed, meanwhile, said they often discussed sleep disruption with patients.


"There was agreement that recognizing and eliciting these early flare symptoms may improve care and even reduce clinic times by averting flares at any earlier stage, although some rheumatologists were clear that limited appointment times meant that these symptoms would not be prioritized for discussion," the authors wrote.


Though Kim acknowledged the possibility of nightmares as prodromal, he noted other ways in which nightmares may be indirectly linked to lupus. "Trauma is a major risk factor for lupus," Kim said, with multiple studies showing childhood traumatic experiences and even posttraumatic stress disorder to be risk factors for lupus. "Whether nightmares represent a traumatic event or prior traumatic events is not clear to me, but one could hypothesize that this may be a manifestation of trauma," Kim said.


In addition, nightmares represent a sleep disorder that can substantially reduce sleep quality, Kim said, and poor sleep is also associated with lupus. "One has to wonder whether disruptive dreaming sleep is one of several specific manifestations of poor sleep quality, which then increases the risk of lupus in those patients," Kim said.


Misattribution of Neuropsychiatric Symptoms


The final theme to emerge from the findings was patients had been misdiagnosed with psychiatric or psychosomatic conditions shortly before getting their rheumatic disease diagnosis. One patient, for example, reported being diagnosed with borderline personality disorder just 6 months before their lupus diagnosis at age 19 and noticed that the symptoms of one "got under control" when the symptoms of the other did.


"Early misattributions of SARD symptoms to primary psychiatric or psychosomatic conditions were frequently reported to have delayed SARD diagnosis and led to future misattributions," the authors reported. "Whilst some of these misdiagnoses likely reflect the widespread lack of knowledge and limited definitive tests for SLE, it is plausible that some early SLE neurological and/or psychiatric symptoms may represent a neuropsychiatric prodrome for SLE itself."


Kim agreed that misattribution of symptoms to other diagnoses is common with lupus and a common reason for delays in diagnosis, even with symptoms that are not neuropsychiatric. The findings in this study broaden "the type of symptoms we need to put on our radar pre-diagnosis," Kim said. "We just also have to be aware that these prodromal symptoms are not diagnostic for lupus, though."


Sloan cited earlier work in recommending an "ABC" approach to improving clinician-patient relationships: "Availability is being accessible when patients need them, Belief is demonstrating belief and validating patient self-reports of symptoms, and Continuity is when the same clinician sees the same patient each clinic visit to build up a trusting relationship." She also noted the importance of asking about and normalizing the existence of these symptoms with rheumatic diseases.


Note: This article originally appeared on Medscape

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