A 25-YEAR OLD WOMAN WITH SLE COMMITTED SUICIDE.

DISCUSS THE
DIFFERENTIAL DIAGNOSIS

(SE October 1991)

Introduction

 Chronic physical illness is an important risk factor for suicide

o Patients with chronic pain – at least 2-fold risk of death by suicide
 2 autoimmune disorders where increased rates of suicidality have been described – SLE &
multiple sclerosis
 4-fold increased risk of suicide among SLE patients than general population
o SLE is a chronic autoimmune disease whose manifestations eg. arthritis are a/w
long-lasting pain
o Neuropsychiatric manifestations in SLE – psychosis, mood disorders, delirium,
anxiety, cognitive dysfunction

Differential diagnosis

 Depression
o 2nd most common neuropsychiatric disorder in SLE (50%)
o May be due to
 Direct neuropsychiatric manifestation of lupus
 Autoimmune antibodies – associated with psychosis, depression,
delirium, coma, cognitive dysfunction
 Reaction to chronic disease
 One of the most stressful aspects of SLE is its unpredictable course,
with sudden exacerbations, remissions & variable prognoses –
resulting in profound loss of control & loss of ability to plan for
future
 Corticosteroid-induced depression
 Corticosteroid causes mood disorders (including depression), mixed
states, psychosis, anxiety, insomnia & delirium
 Pre-existing primary psychiatric disorder
 Psychosis
o Can be a manifestation of direct CNS involvement
 Antiribosomal-P antibodies &antineuronal antibodies – a/w psychosis
o May be due to corticosteroid-induced psychosis
 Delirium
o Common in severe SLE
o May be due to
 Direct manifestation of CNS lupus
 Corticosteroid-induced delirium
 Medical disorders – eg. CNS or systemic infection, renal failure, electrolyte
imbalance, fever, hypertensive encephalopathy, hypoxaemia, comorbid
medical illness
 Anxiety
o Common, often as a reaction to illness
 Psychological reactions to having SLE are common – include anxiety, grief,
depression, regression, denial, invalidism
 Worry that the illness pervades the entire body as SLE can affect many organ
systems
 Fears
 Worsening disease, disability, death
 Cognitive impairment, stroke, renal failure
 Becoming burden on their families
 Mania
o Most common cause is corticosteroid therapy

Distinguishing corticosteroid-induced psychiatric reactions from a flare of CNS lupus is

challenging

Active primary CNS lupus Corticosteroid-induced psychiatric

reaction

Onset After reducing corticosteroid Generally < 2 weeks after increase

dosage / ongoing low-dose in corticosteroid dosage
treatment
(90% within 6 weeks)

Corticosteroid Variable  Rare if < 40mg/day

dosage  Common if > 60mg/day

Psychiatric  Psychosis  Mania / mixed states /

symptoms  Delirium > mood disorders depression (often with
 Cognitive impairment (new psychosis)>> delirium
onset)  Psychosis

SLE symptoms  Often present  Often present

 May coincide with onset of  But precede onset of psychiatric
psychiatric symptoms symptoms

Labs Raised indices of inflammation No specific lab findings

Response to Improvement Exacerbation of symptoms

corticosteroids

Response to Exacerbation Improvement

reduction of
corticosteroid
dose

References

 Textbook of psychosomatic medicine (Levenson, 2005) (pg542)

 Joni