Lupus and Bipolar Disorder

Neuropsychiatric Symptoms with Systemic Lupus Erythematosis (NPSLE)

Lupus and Bipolar Disorder
How are lupus and bipolar disorder related?. Tetra Images / Brand X Pictures / Getty Images

Is lupus related to bipolar disorder or other mental health conditions? What is meant by neuropsychiatric lupus or NPSLE? What might cause psychiatric symptoms in people with lupus?

Lupus (Systemic Lupus Erythematosis or SLE)

Systemic lupus erythematosus (aka Lupus and SLE) is an autoimmune disorder that can cause chronic disease in many different regions of the body. The exact mechanism causing the disease is unknown, but in many ways it represents the immune system gone wild—instead of attacking just foreign substances such as toxins and bacteria, it attacks healthy body tissues.

The signs and symptoms of lupus can involve nearly any organ system of the body but often affects the kidneys, musculoskeletal system, skin, circulatory, and nervous systems.

Why is There a Question About Bipolar Disorder and Lupus?

It is the problems caused in the nervous system that lead to the question of a link between lupus and bipolar disorder. Neuropsychiatric symptoms comprise a wide variety of neurologic and psychiatric features, and are one of the most profound manifestations of the disease.

Lupus may affect the central nervous system, the peripheral nervous system and/or the autonomic nervous system, but it is diffuse symptoms in the central nervous system which have been found to sometimes resemble the symptoms of bipolar disorder.

Yet, while the symptoms of neuropsychiatric lupus and bipolar disorder (and other mental health disorders) can be similar, and they may be treated with the same medications, they are separate and unrelated conditions.

In other words, there is no evidence that bipolar disorder is specifically caused by lupus. These two differing disorders simply have an overlap of symptoms.

Neuropsychiatric Symptoms in People with Lupus (SLE)

There are a wide range of neurological and psychiatric symptoms which may occur in people with lupus.

In fact, these symptoms are thought to be even more common than kidney problems.

NPLSE (for neuropsychiatric systemic lupus erythematosis) is the acronym assigned to the neurologic and psychiatric syndromes which commonly occur with lupus. The frequency of NPLS has been noted to vary from 21 to 95 percent, although in one study only 13 to 38 percent of these symptoms were directly attributable to lupus.

Some of these symptoms include:

  • Headaches
  • Mood disorders including depression and bipolar disorder type symptoms
  • Cognitive problems
  • Seizures
  • Cerebrovascular disease (strokes)
  • Acute confusional states (delirium)
  • Movement disorders
  • Demyelinating syndrome
  • Polyneuropathy

Severity of NPLSE - Neuropsychiatric Lupus

Neuropsychiatric symptoms can be some of the most severe and difficult symptoms for people living with lupus.

What Causes Neuropsychiatric Symptoms?

Rather than one specific cause, the neuropsychiatric symptoms often found in people with lupus are most likely due to a combination of different factors including hormonal and immune imbalances, blood vessel inflammation, damage to nervous tissue from autoantibodies, and inflammatory substances. The blood brain barrier—a tightly knit wall of cells that line the capillaries and keep toxins from entering the central nervous system—may also be disrupted in people with lupus, allowing toxins to pass through and damage neural tissue.

There are some antibodies which tend to be elevated in people with NPLSE more than with lupus (SLE) alone. These include anti-cardiolipin antibodies, lupus anticoagulants, antiphospholipid antibodies, anti-ribosome P antibodies, and antineuronal antibodies.

Lupus Medications and Psychiatric Symptoms

Not only can lupus cause changes in the nervous system (neurologic and psychiatric symptoms) which may resemble mental health disorders such as bipolar disorder or depression, but the medications used to treat lupus may have psychiatric symptoms as a side effect as well.

High doses of corticosteroids (such as prednisone or dexamethasome) are associated with mood disorders, cognitive deficits and may even result in psychosis.

In one study, the incidence of neuropsychiatric symptoms related to the use of high dose prednisolone was much higher than when corticosteroids were used for other types of autoimmune disease.

The prognosis of neuropsychiatric (NP) symptoms related to medications used to treat lupus, however, compared to NP symptoms related to the disease itself, is much better.

Other Conditions Associated With Psychiatric Conditions

The role of the immune system in psychiatric symptoms has been noted for several years. Other conditions related to the immune system in some way, such as HIV infections and Cushing's disease, may also be associated with psychiatric symptoms. The role of the immune system in mediating the psychiatric disturbances, however, is not yet clear.

Treatment of Neuropsychiatric Symptoms with Lupus

In general, medications used to treat primary mental health disorders such as depression or bipolar disorder may also be needed to manage the neuropsychiatric symptoms of lupus. In other words, many of these psychiatric conditions can be managed acutely in a way similar to the management of these conditions without co-existing lupus.

For severe, acute NPSLE treatment often includes high dose corticosteroids such as prednisone or dexamethasone and IV Cytoxan (cyclophosphamide). Other Treatments may include rituximab, IV immunglobulins, or plasmapheresis. Mild to moderate symptoms may be treated with Imuran (azathioprine) and mycophenolate.

Bottom Line on Lupus and Mental Health Disorders Such as Lupus

The nervous system symptoms which can occur with lupus may appear similar to bipolar disorder—and may even be treated in the same way—but this does not indicate a diagnosis of bipolar disorder. That said, the neuropsychiatric symptoms of lupus are very common and can be severe and even life threatening. Thankfully there has been much interest in researching these symptoms in recent years, and new treatments are being evaluated in clinical trials.

Coping

Coping with lupus, whether or not you have neuropsychiatric symptoms, is a challenge. This condition can be even more difficult to cope with as the public does not have a good understanding of the disorder, nor the wide range of symptoms which may occur. Many people find it helpful to become involved in a support group so that they can spend time in-person or online with others who "have been there.' Check out these tips on finding a support group with lupus.

As much or more than with other medical conditions, you will need to be your own advocate in your care. What are the most important tools you need as someone with lupus?

For Friends and Family

If you have a loved one living with lupus, you probably have some idea how difficult this diagnosis can be. Taking a look at some of hurtful things people say to those with lupus highlights this difficulty. As you learn more about the disorder, you may wonder why it is not spoken of more often. Why don't you see ribbons such as the pink ribbons for breast cancer? If your loved one is living with the disease (or it is you who have it) check out these tips on how to become a lupus advocate.

Sources:

Govoni, M., Bortoluzzi, A., Padovan, M. et al. The Diagnosis and Clinical Management of the Neuropsychiatric Manifestations of Lupus. Journal of Autoimmunity. 2016. 74:41-72.

Ho, R., Thiaghu, C., Ong, H. et al. A Meta-Analysis of Serum and Cerebrospinal Fluid Autoantibodies in Neuropsychiatric Systemic Lupus Erythematosis. Autoimmunity Reviews. 2016. 15(2):124-38.

Magro-Checa, C., Zirkzee, E., Huizinga, T., and G. Steup-Beekman. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs. 2016. 76(4):459-83.

Shimizu, Y., Yasuda, S., Kako, Y. et al. Post-Steroid Neuropsychiatric Manifestations are Significantly More Frequent in SLE Compared with Other Systemic Autoimmune Diseases and Predict Better Prognosis Compared with De Novo Neuropsychiatric SLE. Autoimmunity Reviews. 2016. 15(8):786-94.

Tay, S., and A. Mak. Diagnosing and Attributing Neuropsychiatric Events to Systemic Lupus Erythematosus: Time to Untie the Gordian Knot?. Rheumatology (Oxford). 2016 Oct 15. (Epub ahead of print).

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