Pauline Anderson

June 14, 2016

COPENHAGEN — Patients with a neurologic disorder often also have psychiatric symptoms or other problems affecting their quality of life, underlining the importance of looking beyond the neurologic diagnosis.

A special session on stress, sleep, and sexual dysfunction looked at the broader picture of neurological disease here at the Congress of the European Academy of Neurology (EAN) 2016.

Ideally, neurologists would screen all their patients for psychiatric symptoms by using such tools as the Brief Symptom Inventory (BSI), Christian Schmidt-Kraepelin, MD, Department of Psychiatry and Psychotherapy, Heinrich-Heine-University, Düsseldorf, Germany, told his audience, many of them residents and young neurologists.

"It only takes about 15 minutes to do and most patients are relieved to be able to talk about these things."

He also recommended that graduating neurologists work at a psychiatric hospital for a year. "This would give you the option to learn a lot more about psychotherapy and how to build up a good patient relationship."

For example, he said, neurologists in Germany routinely get 1 year of training in psychiatry, which is not the case elsewhere.

Co-occurring Disorders

In clinical practice, psychiatric disorders and neurologic disorders commonly co-occur. But patients are typically treated by either a neurologist or a psychiatrist and rarely by a neuropsychiatrist, or someone trained in both specialties, Dr Schmidt-Kraepelin said.

This, he said, increases the chance of a psychiatric condition going unrecognized and untreated.

In his own department of neuropsychiatry, Dr Schmidt-Kraepelin and his colleagues have developed a neuropsychiatric screening procedure. Patients complete the BSI and the Hospital Anxiety and Depression Scale, with reports containing recommendations being sent to the treating neurologist.

At this meeting, he reported results from 602 patients who completed this procedure.

The extent of psychiatric comorbidity is high. For example, among patients with degenerative disorders, such as Parkinson's disease (PD) and Alzheimer's disease (AD), 17.2% had phobic anxiety and 15.5% had anxiety.

Of those with epileptic disorders, 13.8% had phobic anxiety and 13.0% had paranoid ideation.

And of those with demyelinating disorders, 20.3% were experiencing anxiety, 18.8% had depression, and 17.2% had obsessive-compulsiveness.

It's sometimes difficult to determine whether the psychiatric symptoms are a direct effect of the underlying neurologic disorder or whether there are "reactive factors," said Dr Schmidt-Kraepelin.

In any case, stigmatization is still a problem among neurology patients with psychiatric symptoms. "There are stereotypes that are still out there in the patient population, and also among neurologists."

He says his own neurology colleagues are averse to asking patients about suicidal thoughts for fear that patients would feel offended or stigmatized.

"We as psychiatrists ask this question 20 to 30 times a day; it's not such a taboo thing from our experience because many patients feel relieved" when asked about suicidal thoughts, he said.

His message to young neurologists, he said, is to personally "get to know your colleagues" from psychiatric departments. "This makes it a lot easier to communicate about patients and to get to know the treatment options."

Sleep Issues

During the same session, Wolfgang Oertel, MD, professor, neurology, and director, Department of Neurology, The Philipps University, Marburg, Germany, addressed sleep issues among patients, including those with neurologic conditions.

Sleep disorders, he said, are not uncommon. The most prevalent — insomnia — affects some 10% of the population, with obstructive sleep apnea occurring in 1% to 2%. Restless legs syndrome (RLS) affects 5% to 10% of the population, with up to 3% needing therapy.

The quality of life for patients with RLS is "terrible," said Dr Oertel. Drugs available for this condition only block one dopamine receptor but two are involved in RLS. However, with ongoing research on genetic contributions to this condition, and work on developing an agonist for both dopamine receptors, there's hope that new drugs will soon be available for these patients, said Dr Oertel.

He noted that another sleep disorder — rapid-eye-movement sleep behavior disorder (RBD) — is linked to PD. About 85% of patients with RBD, a condition that involves dream-enacting behavior and aggressive dream content, develop PD, he said.

For most patients, getting 7 hours of sleep every night is "key," said Dr Oertel. The consequences of the brain not sufficiently recharging may be more than just an increased risk for fatigue and accidents. Some research is looking at the role of sleep in the formation of memory and the possibility of a connection between sleep deprivation and AD.

Sexual Issues

Finally, in a separate presentation here, David B. Vodušek, MD, PhD, professor, neurology, University of Ljubljana, Slovenia, addressed sexual dysfunction among neurology patients. He stressed the need for teaching communication skills to medical students and residents and the importance of compassion and "shared respect" in the doctor–patient relationship.

Patient-centered care, said Dr Vodušek, means considering the patients' fears and values as well as their symptoms. Sexual complaints can have a major impact on quality of life. He advises that doctors routinely obtain a patient's sexual history.

All speakers agreed that building trust is a crucial element to the doctor–patient relationship, and this effort doesn't need to be hugely time-consuming. It might, for example, just mean refraining from interrupting patients when they describe their stress or sleep issues, or being careful of body language, whether that is refraining from standing over them in a paternalistic stance or using simple techniques, such as sitting next to them and looking them in the eye.

None of the speakers have disclosed any relevant financial relationships.

Congress of the European Academy of Neurology (EAN) 2016. Abstracts SPS04-1, SPS04-2, and SPS04-3. Presented May 29, 2016.

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