Psychotherapy in MS Patients with Dementia and Personality Changes

Transcription

1 Psychotherapy in MS Patients with Dementia and Personality Changes Ralph HB Benedict, PhD Professor of Neurology University at Buffalo, State University of New York Research Support from the NIH, National MS Society, and Industry Acknowledgements: Bianca Weinstock Guttman MD Robert Zivadinov MD Murali Ramanathan PhD Channa Kolb MD, David Hojnacki MD, Meg Bucello NP Jonathan Rodgers PhD, Audrey Smerbeck PhD, Adam Booth MA, Seth Frndek BS, Carrie Fisher BA, Allison Drake BA, Victoria Kordovski BA, Claire Modica BS, Maria Pollack, Kelly Couglin, Joy Parrish PhD Disclosures: Accorda, Bayer, Biogen Idec, EMD Serono, Genzyme, Genentech, Novartis, Questor 1

2 [In] most of the patients affected by multi-locular sclerosis whom I have had occasion to observe there is marked enfeeblement of the memory; conceptions are formed slowly; the intellectual and emotional faculties are blunted in their totality. The dominant feeling in the patients appears to be a sort of almost cheerful indifference in reference to all things. Jean-Martin Charcot (1877) 2

3 CASE CG Age 51; Male; 16 years Education EDSS = 3.0; nystagmus and ataxia Benedict & Bobholz. Seminars in Neurology, Vol 27, Year 1-51 YO c PP MS, EDSS = 1.0 Year 3 - neurologist suspects cognitive impairment Year 3 - wife discovers losing $40,000 Year 4 - EDSS = 3.0 Year 5 - NP testing shows severe cognitive impairment Year 6 - paroxetine Year 6 - social security disability Year 7 - wife complains of euhphoria and pers dis Year 7 - neuropsychological counseling Year 8 - valproic acid, risperdone 3

4 SCORE Baseline %ile SCORE Year 5 %ile INTERPRETATION Estimated Premorbid Intelligence Barona Regression Formula average Language Cont Oral Word Association NA 11 <1 severe defect Spatial Abilities Judgment of Line Orientation impaired, declined Learning and Memory CVLT List A, Trial <1 severe defect, declined CVLT List B, Trial impaired, unchanged CVLT List A, Trial impaired, unchanged CVLT List A, 20 min Delay impaired, declined CVLT Recognition 89% impaired, declined BVMT R Trial severe defect, declined BVMT R Trial 3 3 <1 6 3 impaired, unchanged BVMT R 20 min Delay 3 <1 4 1 severe defect, declined BVMT R Recognition severe defect, declined Executive Control PASAT, 2.0 sec pacing 14 <1 0 <1 severe defect, declined WCST Categories 5 > impaired, declined WCST Perseverative Responses <1 severe defect, declined.. cheerful. almost stupid indifference in reference to all things. Charcot (1877) 4

5 Subsequent Reports of Personality Changes in MS Hoffman [1904] Agrees with Charcot that euphoria is commonly seen in MS Cottrell [1927] Of 100 consecutive cases, 63 Dx with euphoria Ombredane [1929] Of 50 patients, 36 impaired cognitively and of these 30/36 have disturbance of affect Surridge [1969] Euphoria defined as cheerful complacency out of context to total situation, not always borne out by patient s account of feelings Of 108 patients, 26 euphoric, all but 2 of whom impaired intellectually Majority of euphoric patients exhibit denial of disability and increased sexuality Euphoria and intellectual decline result in great distress to relatives.. cheerful. almost stupid indifference in reference to all things. Charcot (1877) Hoffman (1904); The 1921: 1 st international conference on MS (NY, NY); Cottrell and Wilson (1926); Cottrell (1927); Runge (1928); Ombredane (1929); Surridge (1969); Rabins et al (1986); Feinstein et al (1997); Finger (1998) euphoria = persistently cheerful mood ( mental wellbeing ) Prevalence 0 60% eutonia = lack of awareness or concern about physical disability ( physical well-being ) 5

6 Benedict et al. JNCN. 2001; 13: Neurotic Extrove rt Open Agreeable Consci Em path i c MS MS Normal Methods: Results: 35 referred patients Comprehensive NP Battery Personality testing. Executive Function Defects predict low Agreeableness (p=.02), Empathy (p=.009), Conscientiousness Discrepancy (p=.001) Neuropsychiatric Interview (NPI), Cummings et al, 1994 Factor 1: Agitation/Aggression.85 Euphoria*.87 Disinhibition.78 Irritability/Lability.66 Factor 2: Dysphoria/Depression.73 Anxiety.70 Apathy.73 N=34, most with SP course and cognitive impairment, median EDSS = 3.0 6

7 Results of the regression analysis: SP course elevated MSNQ low agreeableness R 2 =.16, p=.05 R 2 =.48, p <.001 R 2 =.38, p <.001 R 2 =.56 F = 25.34, p <.001 Eutonia/Euphoria Fishmen et al,

8 31 MS patients from Benedict et al (AN; 2004) also had informant report Neuropsychiatric Inventory profiles Depression Euphoria* Disinhibition* TVW BPF Replicates early CT study by Rabins et al STRUCTURAL BRAIN CORRELATES OF EMOTIONAL DISORDER IN MULTIPLE SCLEROSIS. Brain, 109: RHB Benedict, et al. (2004). J Neuroimaging; 14:36S 46S Neuropsychological Counseling Goals: Enhance Insight Cognitive Defects and Behavioral Changes due to Neurological Disorder Improve Interpersonal Empathy Reduce Egocentric Speech Reduce Frequency of Disruptive Behaviors 8

9 Benedict et al. Multiple Sclerosis. 2000; 6: Neuropsychological Counseling 1. PSYCHOEDUCATION: Enhance Insight review MRI review NP Testing agree on defects memorize defects 2. SOCIAL SKILLS TRAINING: Improve social skills and interpersonal empathy caregiver monitoring of target behavior frequency attentive listening empathy conversation skills 3. BEHAVIOR THERAPY: Diminish frequency of disruptive outbursts identify precipitants to target behavior stress inoculation techniques Social Aggression Scale: Range subscales including emotional episodes, inappropriate social behavior, anger outbursts, risk-taking behavior, excessive speech Poorly controlled anger outbursts. Patient loses temper and says something mean that is out of character; may throw objects or breaks things; threaten another person; use profanity. 0 not at all present 1 occurs infrequently, less than once per week 2 occurs frequently, 1 2 times per week 3 occurs very frequently, more than 2 times per week 9

10 SAS Total Scores Normal MS Pre- and Post-Treatment Change Scores Active Placebo Mean SD Mean SD t p Beck Depression Inventory ns Hogan Empathy Scale ns NEO Personality Inventory Altruism ns Competence ns Dutifulness Social Aggression Scale <.01 Notes: All comparisons by t test. Benedict et al. MS. 2000; 6:

11 SAS Scores Exam 1 Exam 2 Normal NC NSP Vocational Status MSQOL-54 Age, Education, etc Disease Features Physical Disability Cognitive Function Fatigue Personality Mood Disorder Behavior Disorder Linear regression analysis in 120 MS patients Benedict et al. J Neurol Sci. 2005;231;

12 Tridimensional Personality Questionnaire (TPQ) 12

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14 Conscientiousness explains how GMV leads to euphoria in al MS pts GMV Euphoria effect is influenced by Neuro cism only in high Neuroticism patients. High neuroticism induces chronically high emotionality and dysregulation of the hypothalamic pituitary adrenal axis. Conclusions There are psychometric tests for personality and neuropsychiatric symptoms in MS: NEOFFI, and NPI Personality is markedly affected in some MS patients, but far fewer than once thought Neuropsychologically focused CBT may be a viable approach for treatment in Neuro cism and in Extraversion and Conscientiousness are risk factors for poor adaptation 14

15 Thank You Bianca Weinstock-Guttman MD Robert Zivadinov MD; Murali Ramanathan PhD David Hojnacki MD; Channa Kolb MD Margaret Bucello NP; Audrey Smerbeck PhD Jonathan Rodgers PhD, Natalie Emmert BA 15