Several studies have suggested that Sjögren’s syndrome may have psychiatric manifestations. In one study, those with the disease were found to be much more highly predisposed to anxiety disorder, depressive disorder and sleep disorder. This should come as no surprise, since electrophysiological scans of those with the disease (especially electroencephalography), report abnormal findings in one third of patients with the disease, to the point of exhibiting severe progressive central nervous system disease.
Such central nervous system complications include focal neurological deficits, diffuse cerebral involvement such as aseptic meningitis, vascular encephalopathy, dementia, and psychiatric disorders. While SS is not primarily a disease of the central nervous system, it clearly does affect the brain significantly in many cases.
“Cox and Hales have suggested that the incidence of mild to moderate psychiatric and/or cognitive impairment may be as high as 80% in patients with CNS-SS. Mental disorder seems to occur most commonly as an ‘atypical’ mood disorder (characterised by a combination of depression, agitation, irritability, somatic symptoms (that is, headache, gastrointestinal disturbances), and mild memory impairment with attention and concentration deficits), which leads to a higher degree of distress and a lower sense of wellbeing. According to Stevenson et al. [6], subjects with primary SS are at increased risk of clinical depression. Therefore, an early recognition and an appropriate intervention are essential to reduce the negative impact of depression on quality of life and outcome.”
Schizophrenia-like psychosis, somatization, panic attacks, anxiety, abnormal personality traits such as paranoia, hostility, hypochondriac and histrionic tendencies, as well as tendencies towards obsessive-compulsive disorder, have also been described. Some researchers believe that these tendencies may be partially due to psychological responses to the stress of having the disease:
“Twenty-one patients with primary Sjogrens’ syndrome were investigated for hostility structure and psychiatric symptomatology. It was observed that they manifested high levels of hostility with an intropunitive direction in combination with highly scored delusional items of guilt and paranoid hostility. Acting-out hostility was in low levels. From the psychopathology point of view the majority of patients reported mainly depression and somatization, as well as anxiety and obsessive-compulsive symptoms. Unexpectedly paranoid symptoms were revealed in a substantial number of these patients. SS patients may present serious psychiatric symptoms and are in need of psychiatric help.”
One case study was particularly notable:
“The patient was a 42-year-old woman who came to our outpatient psychiatry service for the treatment of a depressive episode, characterised by depressed mood, anhedonia, anorexia with weight loss, hypersomnia, diminished libido, and poor concentration. She also reported hopelessness, feelings of sadness, and difficulty at work due to persistent fatigue and abulia. At 2 months prior to her admission, the patient had responded to sertraline at a dose of 75 mg/day, but she stopped the medication because of side effects (sedation and nausea). Her depressive symptoms then recurred and her work difficulty continued.
According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) criteria [9], a ‘major depressive disorder – single episode’ was diagnosed. Bupropion (at a dose of 150 mg/day) was given and partially relieved depressive symptoms (particularly depressed mood, hopelessness, and anhedonia), but did not adequately address fatigue and abulia. Bupropion was administered in order to its smaller propensity for causing sedation and gastrointestinal side effects than selective serotonin reuptake inhibitors (SSRIs).”
So also another case report:
“The patient was a 35-year-old woman who was admitted to our psychiatric hospital for agitation in August 2008. In the 2 months prior to hospitalisation she showed at least three unexpected anxiety episodes with panic features, characterised by palpitations, chest pain, hot flashes, sweating, nausea, trembling and fear of dying. Each episode had been followed by persistent concern about having additional panic attacks and agoraphobia. Phobic situations (such as being outside the home alone and travelling in a bus or in a car) were avoided. The panic attacks were not due to the direct physiological effects of a psychoactive substance or a general medical condition, and were not better accounted for by another mental disorder. The patient had no history of psychiatric and/or somatic illness. At the admission, she referred to a stable and previously satisfying married life and work, and complained of agitation, irritability, difficulty in sleeping, poor concentration, increasing fatigue, weakness, and demoralisation (related to persistent concern about having additional panic attacks). EEG, MRI and a neurological examination were normal.
According to the DSM-IV-TR criteria [9], a diagnosis of ‘panic disorder with agoraphobia’ was formulated. On DSM-IV-TR axis II, a ‘histrionic personality disorder’ was diagnosed (structured clinical interview for DSM-IV axis II personality disorders (SCID-II)). Paroxetine (at a dose of 20 mg/day) and alprazolam (at a dose of 2 mg/day) were given and partially relieved the anxiety symptoms, but did not adequately address fatigue, weakness, and demoralisation. She was discharged to a convalescent home with the prescription to continue her therapy.”
