Advertisement

CNS Drugs

, Volume 21, Issue 6, pp 473–481 | Cite as

Mood and Anxiety Disorders in Patients with Myasthenia Gravis

Aetiology, Diagnosis and Treatment
Therapy In Practice

Abstract

Myasthenia gravis (MG) is a chronic, autoimmune disease involving neuromuscular junctions. It is frequently associated with symptoms such as loss of muscle strength, difficulty in respiration and swallowing, diplopia and ptosis. All chronic diseases, including MG, may have psychiatric consequences in terms of coping and adaptation. Psychiatric morbidity usually appears as anxiety disorders, such as panic disorder and generalised anxiety disorder, and as depressive disorders. However, there are very few data on the prevalence and aetiology of such psychiatric symptoms in patients with MG, and those available in the literature are generally from old studies with poor methodology.

The interaction between MG and psychiatric disorders needs to be appreciated, especially in the primary care setting, since the symptoms may overlap. MG may be under-recognised initially because the psychiatric symptoms may coincide with those of the actual disease, such as fatigue, lack of energy and shortness of breath. On the other hand, co-morbid psychiatric symptoms that appear during the course of the illness may be misdiagnosed as true myasthenic symptoms; thus, leading to unnecessary drug treatment. Differentiation of the aetiology of these symptoms might alter the treatment choice and, therefore, affect the treatment success rate and patients’ well-being. Psychiatric treatments must be carefully planned because of the risk of aggravating the underling neurological disease.

Even though there appears to be an intricate relationship between MG and psychiatric symptoms, there is very limited information on this subject. As such, prospective, randomised, controlled pharmaco/psychotherapy studies are needed to better direct the management of patients and, thus, improve quality of life during the course of the illness.

Keywords

Anxiety Disorder Psychiatric Symptom Somatic Symptom Social Anxiety Disorder Panic Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review.

References

  1. 1.
    Kanner A. Should neurologists be trained to recognize and treat co-morbid depression of neurological disorders? Yes. Epilepsy Behav 2005;6: 303–11PubMedCrossRefGoogle Scholar
  2. 2.
    Cummings J, Mega M, editors. Disturbances of mood and affect in neuropsychiatry and behavioral neuroscience. Oxford: Oxford University Press, 2003: 200–28Google Scholar
  3. 3.
    Cummings J, Mega M, editors. Disturbances of mood and affect in neuropsychiatry and behavioral neuroscience. Oxford: Oxford University Press, 2003: 67–9Google Scholar
  4. 4.
    Kulaksizoglu IB, Giirvit H, Polat A, et al. Unrecognized depression in community-dwelling elderly persons in Istanbul. Int Psychogeriatr 2005; 17(2): 303–12PubMedCrossRefGoogle Scholar
  5. 5.
    Kanner A, Barri JJ. The impact of mood disorders in neurological diseases: should neurologists be concerned? Epilepsy Behav 2003; 4: 3–13CrossRefGoogle Scholar
  6. 6.
    Kupfer DJ, Frank E. Comorbidity in depression. Acta Psychiatr Scand 2003; 418: 57–60CrossRefGoogle Scholar
  7. 7.
    Engel AG. Acquired autoimmune myasthenia gravis. In: Engel AG, Franzini-Armstrong C, editors. Myology. New York: MacGraw-Hill, 1994: 1769–97Google Scholar
  8. 8.
    MacDonald BK, Cockerell OC, Sander JW, et al. The incidence and life-time prevalence of neurological disorders in a prospective community-based study in UK. Brain 2000; 123: 665–76PubMedCrossRefGoogle Scholar
  9. 9.
    Grob D. Clinical manifestations of myasthenia gravis. In: Albuquerque E, Eldefrawi A, editors. Myasthenia gravis. New York: Chapman Hall, 1985: 319–45Google Scholar
  10. 10.
    Seybold M. Diagnosis of myasthenia gravis. In: Engel GA, editor. Myasthenia gravis and myasthenic disorders. Contemporary neurology series. Oxford: Oxford University Press, 1999: 146–60Google Scholar
  11. 11.
    Emery EJ, Szymanski HV. Psychological symptoms preceding diagnosed myasthenia gravis. Psychosomatic 1981; 22(11): 993–5Google Scholar
  12. 12.
    Pourmand R. Myasthenia gravis. Dis Mon 1997 Feb; 43(2): 65–109PubMedCrossRefGoogle Scholar
  13. 13.
    Rohr W. Myasthenia gravis in the frontier of psychiatric diagnosis. Psychiatr Prax 1992 Sep; (19) 5: 157–63Google Scholar
  14. 14.
    Perez-Nellar J, Rodriguez A. False negatives in the diagnosis of myasthenia gravis. Rev Neurol 2000; 30(8): 712–5PubMedGoogle Scholar
  15. 15.
    Nicholson GA, Wilby J, Tennant C. Myasthenia gravis: the problem of a ‘psychiatric’ misdiagnosis. Med J Aust 1986 Jun 9; 144(12): 632–8PubMedGoogle Scholar
  16. 16.
    Cassem NH. Depression. In: Hackett TP, Cassem NH, editors. Massachusetts General Hospital handbook of general hospital psychiatry. Chicago (IL): Year Book Medical Publishers, 1978: 227–61Google Scholar
  17. 17.
    Paul RH, Cohen RA, Goldstein JM, et al. Severity of selfevaluative and vegetative symptoms of depression in myasthenia gravis. J Neuropsychiatry Clin Neurosci 2000; 12(4): 499–501PubMedCrossRefGoogle Scholar
  18. 18.
    Bergonzi P, Mazza S, Mennuni G, et al. Central nervous system involvement in myasthenia gravis. Ann N Y Acad Sci 1981; 377: 810–1CrossRefGoogle Scholar
  19. 19.
    Papazian O. Rapid eye movement sleep alterations in myasthenia gravis. Neurology 1976; 26: 311–6PubMedCrossRefGoogle Scholar
  20. 20.
    Tucker DM, Roeltgen DP, Wann PD, et al. Memory dysfunction in myasthenia gravis: evidence for central cholinergic effects. Neurology 1988; 38: 1173–7PubMedCrossRefGoogle Scholar
  21. 21.
    Davidov-Lusting M, Klinghoffer V, Kaplan-Dinur A, et al. Memory abnormalities in myasthenia gravis: possible fatigue of central nervous system cholinergic circuits. Autoimmunity 1992; 14(1): 85–6PubMedCrossRefGoogle Scholar
  22. 22.
    Keesey J. Does myasthenia gravis affect the brain? J Neurological Sciences 1999; 170: 77–89CrossRefGoogle Scholar
  23. 23.
    Groves M, Muskin P. Psychological responses to illness. In: Levenson J, editor. Textbook of psychosomatic medicine. Washington, DC: American Psychiatric Publishing, 2005: 67–87Google Scholar
  24. 24.
    Lipowski ZJ. Physical illness: the individual and coping process. Psychiatry Med 1970; 1: 91–102PubMedCrossRefGoogle Scholar
  25. 25.
    Meyer E. Psychological disturbances in myasthenia gravis: a predictive study. Ann N Y Acad Sci 1966; 135: 417–23PubMedCrossRefGoogle Scholar
  26. 26.
    Paradis C, Friedman S, Lazar RM, et al. Anxiety disorders in a neuromuscular a clinic. Am J Psychiatry 1993; 150(7): 1102–4PubMedGoogle Scholar
  27. 27.
    Sneddon J. Myasthenia gravis: a study of social, medical and emotional problems in 26 patients. Lancet 1980: 526-8Google Scholar
  28. 28.
    MacKenzie KR, Martin MJ, Howard FM. Myasthenia gravis: psychiatric concomitants. Can Med Assoc J 1969; 100: 988–91PubMedGoogle Scholar
  29. 29.
    Marcus J. The interrelations of myasthenia gravis and psychiatric stress: presentation of a case. Israel Med J 1962; 21: 178–83PubMedGoogle Scholar
  30. 30.
    Oosterhuis HJ, Wilde GJS. Psychiatric aspects of myasthenia gravis. Psychiatr Neurol Neurochir 1964; 67: 484–96PubMedGoogle Scholar
  31. 31.
    Magni G, Micaglio G, Ceccato MB, et al. The role of life events in myasthenia gravis outcome: a one-year longitudinal study. Acta Neurol Scand 1989; 79: 288–91PubMedCrossRefGoogle Scholar
  32. 32.
    Osserman KE, Genkins G. Studies in myasthenia gravis: review of a twenty-year experience in over 1200 patients. Mt Sinai J Med 1971; 38: 497PubMedGoogle Scholar
  33. 33.
    Knieling J, Weiss H, Faller H, et al. Psychosocial causal attributions by myasthenia gravis patients: a longitudinal study of the significance of subjective illness theories after diagnosis and in the follow up. Psychother Psychosom Med Psychol 1995 Nov; 45(11): 373–80PubMedGoogle Scholar
  34. 34.
    Knieling J, Weiss H, Faller H, et al. Follow up of myasthenia gravis: results of a longitudinal study of significance of psychosocial predictors. Nervenarzt 1998 Feb; 69(2): 137–44PubMedCrossRefGoogle Scholar
  35. 35.
    Magni G, Micaglio G, Lalli R, et al. Psychiatric disturbances associated with myasthenia gravis. Acta Psychiatr Scand 1988; 77: 443–5PubMedCrossRefGoogle Scholar
  36. 36.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980Google Scholar
  37. 37.
    Doering S, Henze T, Schüssler G. Coping with illness in myasthenia gravis. Nervenarzt 1993 Oct; 64(10): 640–7PubMedGoogle Scholar
  38. 38.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed., rev. Washington, DC: American Psychiatric Association, 1987Google Scholar
  39. 39.
    World Health Organization. International classification of diseases. 10th ed. [online]. Available from URL: http://www.who.int/classifications/apps/icd/icd10online [Accessed 2007 May 17]
  40. 40.
    Eren I, Kulaksizoglu IB, Anuk D, et al. Post traumatic stress disorder in myasthenia gravis patients [abstract]. ESTSS 6th European Congress on Traumatic Stress; 1999 Jun 5–8: Istanbul, 147-8Google Scholar
  41. 41.
    Diagnostic and statistical manual of mental disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association, 2000Google Scholar
  42. 42.
    Spitzer RL, Williams JB, Gibbon M, et al. The structured clinical interview for DSMIII-R (SCID-I): history, rationale, and description. Arch Gen Psychiatry 1992; 49: 624PubMedCrossRefGoogle Scholar
  43. 43.
    Rohr W. Situational anxiety in myasthenia gravis. Psychother Psycosom Med Psychol 1993 Apr; 43 (3–4): 93–9Google Scholar
  44. 44.
    Paul R, Cohen R, Goldstein J, et al. Severity of mood, self evaluative and vegetative symptoms of depression in myasthenia gravis. J Neuropsychiatry Clin Neurosci 2000 Fall; 12(4): 499–501PubMedCrossRefGoogle Scholar
  45. 45.
    Paul R, Nash J, Cohen R. Quality of life and well-being of patients with myasthenia gravis. Muscle Nerve 2001 Apr; 24(4): 512–6PubMedCrossRefGoogle Scholar
  46. 46.
    Skeie O, Apolstolski S, Evoli A, et al. Guidelines for the treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol 2006; 13(7): 691–9PubMedCrossRefGoogle Scholar
  47. 47.
    Brown ES, Suppes T. Mood symptoms during corticosteroid therapy: a review. Harvard Rev Psych 1998; 5: 239–46CrossRefGoogle Scholar
  48. 48.
    Schmidt LA, Fox NA, Goldberg MC, et al. Effects of acute prednisone administration on memory, attention, and emotion in healthy human adults. Psychoneuroimmunol 1999; 24(4): 461–83Google Scholar
  49. 49.
    Warrington TP, Botswick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc 2006; 81(10): 1361–7PubMedCrossRefGoogle Scholar
  50. 50.
    Schwartz ML, Cahill R. Psychopathology associated with myasthenia gravis and its treatment by psychotherapeutically oriented group counseling. J Chron Dis 1971; 24: 543–52PubMedCrossRefGoogle Scholar
  51. 51.
    Kütemeyer M. Symptom changes during the psychotherapy of patients with myasthenia gravis. Psychother Psychosom 1979; 32: 279–86PubMedCrossRefGoogle Scholar
  52. 52.
    Achiron A, Barak Y, Noy S, et al. Fluoxetine treatment for weight reduction in steroid-induced obesity: a pilot study in myasthenia gravis patients. Euro Psychopharmacol 1999; 9: 111–3Google Scholar
  53. 53.
    Kulaksizoglu IB, Aldemir D, Parman Y, et al. Citalopram treatment of depression in myasthenia gravis patients: an open study [abstract]. European Congress of Neuropsychopharmacology; 2005 Oct 22–26; Amsterdam, 426Google Scholar
  54. 54.
    Seybold M. Treatment of myasthenia gravis. In: Engel GA, editor. Myasthenia gravis and myasthenic disorders. Contemporary neurology series. Oxford: Oxford University Press, 1999: 167–201Google Scholar
  55. 55.
    Argov Z, Mastaglia FL. Disorders of neuromuscular transmission caused by drugs. N Engl J Med 1979; 30: 409–13Google Scholar
  56. 56.
    Howard JR. Adverse drug effects on neuromuscular transmission. Sem Neurol 1990; 10: 89–102CrossRefGoogle Scholar
  57. 57.
    McQuillen MP, Gross M, Johns RJ. Chlorpromazine-induced weakness in myasthenia gravis. Arch Neurol 1963; 8: 286–90PubMedCrossRefGoogle Scholar
  58. 58.
    Argov Z, Yaari Y. The action of chlorpromazine at an isolated cholinergic synapse. Brain Research 1979; 164: 227–36PubMedCrossRefGoogle Scholar
  59. 59.
    Kramer M. Hypnotic medication in the treatment of chronic insomnia: non nocere! Doesn’t anyone care? Sleep Med Rev 2000 Dec; 4(6): 529–41PubMedCrossRefGoogle Scholar
  60. 60.
    Neil JF, Himmelhoch JM, Licata SM. Emergence of myasthenia gravis during treatment with lithium carbonate. Arch Gen Psychiatry 1976; 33: 1090–2PubMedCrossRefGoogle Scholar
  61. 61.
    Granacher RP. Neuromuscular problems associated with lithium. Am J Psychiatry 1977; 134: 702PubMedGoogle Scholar
  62. 62.
    Lipton ID. Myasthenia gravis unmasked by lithium carbonate [letter]. J Clin Psychopharmacol 1987; 7: 57PubMedCrossRefGoogle Scholar
  63. 63.
    Vizi ES, Illes P, Ronai A, et al. The effect of lithium on acetylcholine release and synthesis. Neuropharmacology 1972; 11: 521–30PubMedCrossRefGoogle Scholar
  64. 64.
    Hill GE, Wong KC, Hodges MR. Potentiation of succinylcholine neuromuscular blockage by lithium carbonate. Anesthesiology 1976; 44: 439–42PubMedCrossRefGoogle Scholar
  65. 65.
    Lai CW, Leppik IE, Jenkins DC, et al. Epilepsy, myasthenia gravis, and effect of plasmapheresis on antiepileptic drug concentrations. Arch Neurol 1990 Jan; 47(1): 66–8PubMedCrossRefGoogle Scholar
  66. 66.
    Siddiqi ZA, Holt A, Ahmed SN. Effect of plasma exchange on carbamazepine levels in a patient with myasthenia gravis and epilepsy. Epilepsia 2005 Nov; 46(11): 1841–2PubMedCrossRefGoogle Scholar
  67. 67.
    Pande AC, Grunhaus LJ. ECT for depression in the presence of myasthenia gravis. Convuls Ther 1990; 6(2): 172–5PubMedGoogle Scholar
  68. 68.
    Calarge CA, Crowe RR. Electroconvulsive therapy in myasthenia gravis. Ann Clin Psychiatry 2004 Oct–Dec; 16(4): 225–7PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2007

Authors and Affiliations

  1. 1.Psychiatry DepartmentIstanbul University, Istanbul Medical SchoolCapa, IstanbulTurkey

Personalised recommendations